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Clouse K, Noholoza S, Madwayi S, Mrubata M, Robbins NN, Camlin CS, Myer L, Phillips TK. Peripartum mobility and maternal/child separation among women living with HIV in South Africa. AIDS Care 2024; 36:946-953. [PMID: 38176056 PMCID: PMC11222306 DOI: 10.1080/09540121.2023.2299745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 12/18/2023] [Indexed: 01/06/2024]
Abstract
This prospective cohort study investigated the mobility patterns of 200 pregnant and postpartum women living with HIV in South Africa. Participants were enrolled during their third trimester from routine antenatal care near Cape Town, South Africa, and followed for six months postpartum. Quantitative data were collected at enrollment and follow-up. Mobility (self-reported) was common among the participants, despite the brief study period and the concurrent COVID-19 pandemic. While most reported stability in their current residence, 71% had a second main residence, primarily in the Eastern Cape (EC). Participants had a median of two lifetime moves, motivated by work, education, and family life. During the study period, 20% of participants met the study definition of travel (>7 days and >50 km), with trips predominantly to the EC, lasting a median duration of 30 days. Over one-third of participants with other living children reported that these children lived apart from them, with the mother's family being primary caregivers. These findings emphasize the need for targeted interventions to support continuity of care for mobile populations, particularly peripartum women living with HIV. The study contributes valuable insights into mobility dynamics and highlights unique barriers faced by this population, contributing to improved HIV care in resource-limited settings.
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Affiliation(s)
- Kate Clouse
- Vanderbilt University School of Nursing, Vanderbilt University, Nashville, TN, USA
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sandisiwe Noholoza
- Division of Epidemiology and Biostatistics, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Sindiswa Madwayi
- Division of Epidemiology and Biostatistics, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Megan Mrubata
- Division of Epidemiology and Biostatistics, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Natalie N. Robbins
- Vanderbilt Institute for Spatial Research, Vanderbilt University, Nashville, TN, USA
| | - Carol S. Camlin
- University of California, San Francisco, Department of Obstetrics, Gynecology & Reproductive Sciences, San Francisco, CA, USA
| | - Landon Myer
- Division of Epidemiology and Biostatistics, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Tamsin K. Phillips
- Division of Epidemiology and Biostatistics, School of Public Health, University of Cape Town, Cape Town, South Africa
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Rossouw L, Ngcobo N, Clouse K, Nattey C, Technau KG, Maskew M. Augmenting maternal clinical cohort data with administrative laboratory dataset linkages: a validation study. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.06.19.24309149. [PMID: 38946964 PMCID: PMC11213096 DOI: 10.1101/2024.06.19.24309149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/02/2024]
Abstract
Background The use of big data and large language models in healthcare can play a key role in improving patient treatment and healthcare management, especially when applied to large-scale administrative data. A major challenge to achieving this is ensuring that patient confidentiality and personal information is protected. One way to overcome this is by augmenting clinical data with administrative laboratory dataset linkages in order to avoid the use of demographic information. Methods We explored an alternative method to examine patient files from a large administrative dataset in South Africa (the National Health Laboratory Services, or NHLS), by linking external data to the NHLS database using specimen barcodes associated with laboratory tests. This offers us with a deterministic way of performing data linkages without accessing demographic information. In this paper, we quantify the performance metrics of this approach. Results The linkage of the large NHLS data to external hospital data using specimen barcodes achieved a 95% success. Out of the 1200 records in the validation sample, 87% were exact matches and 9% were matches with typographic correction. The remaining 5% were either complete mismatches or were due to duplicates in the administrative data. Conclusions The high success rate indicates the reliability of using barcodes for linking data without demographic identifiers. Specimen barcodes are an effective tool for deterministic linking in health data, and may provide a method of creating large, linked data sets without compromising patient confidentiality.
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Affiliation(s)
- Laura Rossouw
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand
| | - Nkosinathi Ngcobo
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand
| | - Kate Clouse
- Vanderbilt University School of Nursing, Vanderbilt University, Nashville, TN, USA; Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Cornelius Nattey
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand
| | - Karl-Günter Technau
- Empilweni Services and Research Unit (ESRU), Rahima Moosa Mother and Child Hospital, Department of Paediatrics and Child Health, Faculty of Health Sciences, University of The Witwatersrand
| | - Mhairi Maskew
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand
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Rosen JG, Ndyanabo A, Nakawooya H, Galiwango RM, Ssekubugu R, Ssekasanvu J, Kim S, Rucinski KB, Nakigozi G, Nalugoda F, Kigozi G, Quinn TC, Chang LW, Kennedy CE, Reynolds SJ, Kagaayi J, Grabowski MK. Incidence of Health Facility Switching and Associations With HIV Viral Rebound Among Persons on Antiretroviral Therapy in Uganda: A Population-based Study. Clin Infect Dis 2024; 78:1591-1600. [PMID: 38114162 PMCID: PMC11175689 DOI: 10.1093/cid/ciad773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 12/02/2023] [Accepted: 12/14/2023] [Indexed: 12/21/2023] Open
Abstract
BACKGROUND A substantial proportion of persons on antiretroviral therapy (ART) considered lost to follow-up have actually transferred their human immunodeficiency virus (HIV) care to other facilities. However, the relationship between facility switching and virologic outcomes, including viral rebound, is poorly understood. METHODS We used data from 40 communities (2015-2020) in the Rakai Community Cohort Study to estimate incidence of facility switching and viral rebound. Persons aged 15-49 years with serologically confirmed HIV who self-reported ART use and contributed ≥1 follow-up visit were included. Facility switching and virologic outcomes were assessed between 2 consecutive study visits (ie, index and follow-up visits, interval of approximately 18 months). Those who reported different HIV treatment facilities between index and follow-up study visits were classified as having switched facilities. Virologic outcomes included viral rebound among individuals initially suppressed (<200 copies/mL). Multivariable Poisson regression was used to estimate associations between facility switching and viral rebound. RESULTS Overall, 2257 persons who self-reported ART use (median age, 35 years; 65% female, 92% initially suppressed) contributed 3335 visit-pairs and 5959 person-years to the analysis. Facility switching was common (4.8 per 100 person-years; 95% confidence interval [CI], 4.2-5.5) and most pronounced in persons aged <30 years and fishing community residents. Among persons suppressed at their index visit (n = 2076), incidence of viral rebound was more than twice as high in persons who switched facilities (adjusted incidence rate ratio = 2.27; 95% CI, 1.16-4.45). CONCLUSIONS Facility switching was common and associated with viral rebound among persons initially suppressed. Investments in more agile, person-centered models for mobile clients are needed to address system inefficiencies and bottlenecks that can disrupt HIV care continuity.
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Affiliation(s)
- Joseph G Rosen
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | | | | | | | | | | | - Seungwon Kim
- Department of Pathology, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Katherine B Rucinski
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | | | | | | | - Thomas C Quinn
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
- Rakai Health Sciences Program, Entebbe, Uganda
- Division of Infectious Diseases, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Larry W Chang
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
- Rakai Health Sciences Program, Entebbe, Uganda
- Division of Infectious Diseases, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Caitlin E Kennedy
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
- Rakai Health Sciences Program, Entebbe, Uganda
| | - Steven J Reynolds
- Rakai Health Sciences Program, Entebbe, Uganda
- Division of Infectious Diseases, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | | | - M Kate Grabowski
- Rakai Health Sciences Program, Entebbe, Uganda
- Department of Pathology, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
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Haeri Mazanderani A, Radebe L, Sherman GG. Attrition Rates in HIV Viral Load Monitoring and Factors Associated With Overdue Testing Among Children Within South Africa's Antiretroviral Treatment Program: Retrospective Descriptive Analysis. JMIR Public Health Surveill 2024; 10:e40796. [PMID: 38743934 PMCID: PMC11134236 DOI: 10.2196/40796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 12/25/2023] [Accepted: 02/27/2024] [Indexed: 05/16/2024] Open
Abstract
BACKGROUND Numerous studies in South Africa have reported low HIV viral load (VL) suppression and high attrition rates within the pediatric HIV treatment program. OBJECTIVE Using routine laboratory data, we evaluated HIV VL monitoring, including mobility and overdue VL (OVL) testing, within 5 priority districts in South Africa. METHODS We performed a retrospective descriptive analysis of National Health Laboratory Service (NHLS) data for children and adolescents aged 1-15 years having undergone HIV VL testing between May 1, 2019, and April 30, 2020, from 152 facilities within the City of Johannesburg, City of Tshwane, eThekwini, uMgungundlovu, and Zululand. HIV VL test-level data were deduplicated to patient-level data using the NHLS CDW (Corporate Data Warehouse) probabilistic record-linking algorithm and then further manually deduplicated. An OVL was defined as no subsequent VL determined within 18 months of the last test. Variables associated with the last VL test, including age, sex, VL findings, district type, and facility type, are described. A multivariate logistic regression analysis was performed to identify variables associated with an OVL test. RESULTS Among 21,338 children and adolescents aged 1-15 years who had an HIV VL test, 72.70% (n=15,512) had a follow-up VL test within 18 months. Furthermore, 13.33% (n=2194) of them were followed up at a different facility, of whom 3.79% (n=624) were in a different district and 1.71% (n=281) were in a different province. Among patients with a VL of ≥1000 RNA copies/mL of plasma, the median time to subsequent testing was 6 (IQR 4-10) months. The younger the age of the patient, the greater the proportion with an OVL, ranging from a peak of 52% among 1-year-olds to a trough of 21% among 14-year-olds. On multivariate analysis, 2 consecutive HIV VL findings of ≥1000 RNA copies/mL of plasma were associated with an increased adjusted odds ratio (AOR) of having an OVL (AOR 2.07, 95% CI 1.71-2.51). Conversely, patients examined at a hospital (AOR 0.86, 95% CI 0.77-0.96), those with ≥2 previous tests (AOR 0.78, 95% CI 0.70-0.86), those examined in a rural district (AOR 0.63, 95% CI 0.54-0.73), and older age groups of 5-9 years (AOR 0.56, 95% CI 0.47-0.65) and 10-14 years (AOR 0.51, 95% CI 0.44-0.59) compared to 1-4 years were associated with a significantly decreased odds of having an OVL test. CONCLUSIONS Considerable attrition occurs within South Africa's pediatric HIV treatment program, with over one-fourth of children having an OVL test 18 months subsequent to their previous test. In particular, younger children and those with virological failure were found to be at increased risk of having an OVL test. Improved HIV VL monitoring is essential for improving outcomes within South Africa's pediatric antiretroviral treatment program.
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Affiliation(s)
- Ahmad Haeri Mazanderani
- Centre for HIV & STIs, National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa
- Department of Paediatrics & Child Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Paediatric HIV Diagnostics Division, Wits Health Consortium, University of the Witwatersrand, Johannesburg, South Africa
| | - Lebohang Radebe
- Centre for HIV & STIs, National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa
- Paediatric HIV Diagnostics Division, Wits Health Consortium, University of the Witwatersrand, Johannesburg, South Africa
| | - Gayle G Sherman
- Centre for HIV & STIs, National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa
- Department of Paediatrics & Child Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Paediatric HIV Diagnostics Division, Wits Health Consortium, University of the Witwatersrand, Johannesburg, South Africa
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Nardell MF, Govathson C, Mngadi-Ncube S, Ngcobo N, Letswalo D, Lurie M, Miot J, Long L, Katz IT, Pascoe S. Migrant men and HIV care engagement in Johannesburg, South Africa. BMC Public Health 2024; 24:435. [PMID: 38347453 PMCID: PMC10860300 DOI: 10.1186/s12889-024-17833-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 01/20/2024] [Indexed: 02/15/2024] Open
Abstract
BACKGROUND South Africa (SA) has one of the highest rates of migration on the continent, largely comprised of men seeking labor opportunities in urban centers. Migrant men are at risk for challenges engaging in HIV care. However, rates of HIV and patterns of healthcare engagement among migrant men in urban Johannesburg are poorly understood. METHODS We analyzed data from 150 adult men (≥ 18 years) recruited in 10/2020-11/2020 at one of five sites in Johannesburg, Gauteng Province, SA where migrants typically gather for work, shelter, transit, or leisure: a factory, building materials store, homeless shelter, taxi rank, and public park. Participants were surveyed to assess migration factors (e.g., birth location, residency status), self-reported HIV status, and use and knowledge of HIV and general health services. Proportions were calculated with descriptive statistics. Associations between migration factors and health outcomes were examined with Fisher exact tests and logistic regression models. Internal migrants, who travel within the country, were defined as South African men born outside Gauteng Province. International migrants were defined as men born outside SA. RESULTS Two fifths (60/150, 40%) of participants were internal migrants and one fifth (33/150, 22%) were international migrants. More internal migrants reported living with HIV than non-migrants (20% vs 6%, p = 0.042), though in a multi-variate analysis controlling for age, being an internal migrant was not a significant predictor of self-reported HIV positive status. Over 90% all participants had undergone an HIV test in their lifetime. Less than 20% of all participants had heard of pre-exposure prophylaxis (PrEP), with only 12% international migrants having familiarity with PrEP. Over twice as many individuals without permanent residency or citizenship reported "never visiting a health facility," as compared to citizens/permanent residents (28.6% vs. 10.6%, p = 0.073). CONCLUSIONS Our study revealed a high proportion of migrants within our community-based sample of men and demonstrated a need for HIV and other healthcare services that effectively reach migrants in Johannesburg. Future research is warranted to further disaggregate this heterogenous population by different dimensions of mobility and to understand how to design HIV programs in ways that will address migrants' challenges.
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Affiliation(s)
- Maria Francesca Nardell
- Division of Global Health Equity, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA.
- Harvard Medical School, Boston, MA, USA.
| | - Caroline Govathson
- Health Economics and Epidemiology Research Office (HE2RO), Johannesburg, South Africa
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Sithabile Mngadi-Ncube
- Health Economics and Epidemiology Research Office (HE2RO), Johannesburg, South Africa
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Nkosinathi Ngcobo
- Health Economics and Epidemiology Research Office (HE2RO), Johannesburg, South Africa
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Daniel Letswalo
- Health Economics and Epidemiology Research Office (HE2RO), Johannesburg, South Africa
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mark Lurie
- Brown University School of Public Health, Brown University, Providence, Rhode Island, USA
| | - Jacqui Miot
- Health Economics and Epidemiology Research Office (HE2RO), Johannesburg, South Africa
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Lawrence Long
- Health Economics and Epidemiology Research Office (HE2RO), Johannesburg, South Africa
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | - Ingrid Theresa Katz
- Harvard Medical School, Boston, MA, USA
- Division of Women's Health, Brigham and Women's Hospital, Boston, MA, USA
| | - Sophie Pascoe
- Health Economics and Epidemiology Research Office (HE2RO), Johannesburg, South Africa
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Urrio RF, Lyatuu GW, Sando D, Mahande MJ, Philipo E, Naburi H, Lyaruu P, Kimonge A, Mayogu K, Simba B, Kibao AM, Msangi M, Zeebari Z, Biberfeld G, Ekström AM, Kilewo C, Kågesten AE. Long-term retention on antiretroviral treatment after enrolment in prevention of vertical HIV transmission services: a prospective cohort study in Dar es Salaam, Tanzania. J Int AIDS Soc 2024; 27:e26186. [PMID: 38332522 PMCID: PMC10853596 DOI: 10.1002/jia2.26186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Accepted: 10/09/2023] [Indexed: 02/10/2024] Open
Abstract
INTRODUCTION To prevent vertical HIV transmission and ensure healthy mothers and children, pregnant women with HIV must remain on antiretroviral treatment (ART) for life. However, motivation to remain on ART may decline beyond the standard 2-year breastfeeding/postpartum period. We assessed attrition and retention in ART care among women with HIV up to 6 years since enrolment in vertical transmission prevention services in Dar es Salaam, Tanzania. METHODS A prospective cohort of 22,631 pregnant women with HIV were enrolled in vertical transmission prevention services between January 2015 and December 2017 in routine healthcare settings and followed-up to July 2021. Kaplan-Meier was used to estimate time to ART attrition (died, stopped ART or was lost to follow-up [no show ≥90 days since scheduled appointment]) and the proportion retained in care. Cox proportional hazard models were used to estimate adjusted hazard ratios (aHR) of ART attrition in relation to predictors. RESULTS Participants were followed-up to 6 years for a median of 3 years (IQR: 0.1-4). The overall ART attrition rate was 13.8 per 100 person-years (95% CI: 13.5-14.1), highest in the first year of enrolment at 27.1 (26.3-27.9), thereafter declined to 9.5 (8.9-10.1) in year 3 and 2.7 (2.1-3.5) in year 6. The proportion of women retained in care were 78%, 69%, 63%, 60%, 57% and 56% at 1, 2, 3, 4, 5 and 6 years, respectively. ART attrition was higher in young women aged <20 years (aHR 1.63, 95% CI: 1.38-1.92) as compared to 30-39 year-olds and women enrolled late in the third versus first trimester (aHR 1.29, 95% CI: 1.16-1.44). In contrast, attrition was lower in older women ≥40 years, women who initiated ART before versus during the index pregnancy and women attending higher-level health facilities. CONCLUSIONS ART attrition among women with HIV remains highest in the first year of enrolment in vertical transmission prevention services and declines markedly following a transition to chronic HIV care. Targeted interventions to improve ART continuity among women with HIV during and beyond prevention of vertical transmission are vital to ending paediatric HIV and keeping women and children alive and healthy.
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Affiliation(s)
- Roseline Faustine Urrio
- Management and Development for HealthDar es SalaamTanzania
- Department of Obstetrics and GynacologyMuhimbili University of Health and Allied SciencesDar es SalaamTanzania
| | - Goodluck Willey Lyatuu
- Management and Development for HealthDar es SalaamTanzania
- Department of Global Public HealthKarolinska InstitutetStockholmSweden
| | - David Sando
- Management and Development for HealthDar es SalaamTanzania
| | | | | | - Helga Naburi
- Department of Pediatric and Child HealthMuhimbili University of Health and Allied SciencesDar es SalaamTanzania
| | - Peter Lyaruu
- Management and Development for HealthDar es SalaamTanzania
| | - Amanda Kimonge
- Management and Development for HealthDar es SalaamTanzania
| | - Kasasi Mayogu
- Management and Development for HealthDar es SalaamTanzania
| | - Brenda Simba
- Management and Development for HealthDar es SalaamTanzania
| | | | | | - Zangin Zeebari
- Department of Global Public HealthKarolinska InstitutetStockholmSweden
| | - Gunnel Biberfeld
- Department of Global Public HealthKarolinska InstitutetStockholmSweden
| | - Anna Mia Ekström
- Department of Global Public HealthKarolinska InstitutetStockholmSweden
- Department of Infectious Disease/VenhälsanSouth General HospitalStockholmSweden
| | - Charles Kilewo
- Department of Obstetrics and GynacologyMuhimbili University of Health and Allied SciencesDar es SalaamTanzania
| | - Anna E. Kågesten
- Department of Global Public HealthKarolinska InstitutetStockholmSweden
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Odayar J, Myer L, Kabanda S, Knight L. Experiences of transfer of care among postpartum women living with HIV attending primary healthcare services in South Africa. Glob Public Health 2024; 19:2356624. [PMID: 38820565 DOI: 10.1080/17441692.2024.2356624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 05/13/2024] [Indexed: 06/02/2024]
Abstract
Transfers between health facilities for postpartum women living with HIV are associated with disengagement from care. In South Africa, women must transfer from integrated antenatal/HIV care to general HIV services post-delivery. Thereafter, women transfer frequently e.g. due to geographic mobility. To explore barriers to transfer, we conducted in-depth interviews >2 years post-delivery in 28 participants in a trial comparing postpartum HIV care at primary health care (PHC) antiretroviral therapy (ART) facilities versus a differentiated service delivery model, the adherence clubs, which are the predominant model implemented in South Africa. Data were thematically analysed using inductive and deductive approaches. Women lacked information including where they could transfer to and transfer processes. Continuity mechanisms were affected when women transferred silently i.e. without informing facilities or obtaining referral letters. Silent transfers often occurred due to poor relationships with healthcare workers and were managed inconsistently. Fear of disclosure to family and community stigma led to transfers from local PHC ART facilities to facilities further away affecting accessibility. Mobility and the postpartum period presented unique challenges requiring specific attention. Information regarding long-term care options and transfer processes, ongoing counselling regarding disclosure and social support, and increased health system flexibility are required.
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Affiliation(s)
- Jasantha Odayar
- Division of Epidemiology & Biostatistics, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Landon Myer
- Division of Epidemiology & Biostatistics, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Siti Kabanda
- Division of Epidemiology & Biostatistics, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Lucia Knight
- Division of Social and Behavioural Sciences, School of Public Health, University of Cape Town, Cape Town, South Africa
- School of Public Health, University of the Western Cape, Bellville, South Africa
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Ayieko J, Thorp M, Getahun M, Gandhi M, Maeri I, Gutin SA, Okiring J, Kamya MR, Bukusi EA, Charlebois ED, Petersen M, Havlir DV, Camlin CS, Murnane PM. Geographic Mobility and HIV Care Engagement among People Living with HIV in Rural Kenya and Uganda. Trop Med Infect Dis 2023; 8:496. [PMID: 37999615 PMCID: PMC10675546 DOI: 10.3390/tropicalmed8110496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 10/31/2023] [Accepted: 11/08/2023] [Indexed: 11/25/2023] Open
Abstract
INTRODUCTION Human mobility is a critical aspect of existence and survival, but may compromise care engagement among people living with HIV (PLHIV). We examined the association between various forms of human mobility with retention in HIV care and antiretroviral treatment (ART) interruptions. METHODS In a cohort of adult PLHIV in Kenya and Uganda, we collected surveys in 2016 about past 6-month travel and lifetime migration histories, including reasons and locations, and engagement in HIV care defined as (1) discontinuation of care, and (2) history of a treatment interruption among those who remained in care. We estimated associations between mobility and these care engagement outcomes via logistic regression, adjusted for sex, prior mobility, age, region, marital status, household wealth, and education. RESULTS Among 1081 participants, 56 (5%) reported having discontinued care; among those in care, 104 (10%) reported treatment interruption. Past-year migration was associated with a higher risk of discontinuation of care (adjusted odds ratio [aOR] 1.98, 95% CI 1.08-3.63). In sex-stratified models, the association was somewhat attenuated in women, but remained robust among men. Past-year migration was associated with reduced odds of having a treatment interruption among men (aOR 0.51, 95% CI 0.34-0.77) but not among women (aOR 2.67, 95% CI 0.78, 9.16). Travel in the past 6 months was not associated with discontinuation of care or treatment interruptions. CONCLUSIONS We observed both negative and protective effects of recent migration on care engagement and ART use that were most pronounced among men in this cohort. Migration can break ties to ongoing care, but for men, who have more agency in the decision to migrate, may foster new care and treatment strategies. Strategies that enable health facilities to support individuals throughout the process of transferring care could alleviate the risk of care disengagement.
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Affiliation(s)
- James Ayieko
- Kenya Medical Research Institute, Center for Microbiology Research, Nairobi 00200, Kenya
| | - Marguerite Thorp
- Division of Infectious Diseases, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA 90024, USA
| | - Monica Getahun
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, CA 94143, USA
| | - Monica Gandhi
- Division of HIV, Infectious Diseases and Global Medicine, Department of Medicine, University of California, San Francisco, CA 94143, USA
| | - Irene Maeri
- Kenya Medical Research Institute, Center for Microbiology Research, Nairobi 00200, Kenya
| | - Sarah A. Gutin
- Department of Community Health Systems, School of Nursing, University of California, San Francisco, CA 94143, USA
| | - Jaffer Okiring
- Clinical Epidemiology Unit, School of Medicine, College of Health Sciences, Makerere University, Kampala P.O. Box 7072, Uganda
| | - Moses R. Kamya
- School of Medicine, Makerere University, Kampala P.O. Box 7072, Uganda
| | - Elizabeth A. Bukusi
- Kenya Medical Research Institute, Center for Microbiology Research, Nairobi 00200, Kenya
| | - Edwin D. Charlebois
- Center for AIDS Prevention Studies, Department of Medicine, University of California, San Francisco, CA 94143, USA
| | - Maya Petersen
- Division of Biostatistics, University of California, Berkeley, CA 94720, USA
| | - Diane V. Havlir
- Division of HIV, Infectious Diseases and Global Medicine, Department of Medicine, University of California, San Francisco, CA 94143, USA
| | - Carol S. Camlin
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, CA 94143, USA
| | - Pamela M. Murnane
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA 94143, USA
- Institute for Global Health Sciences, University of California, San Francisco, CA 94143, USA
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Odayar J, Phillips TK, Kabanda S, Malaba TR, Mukonda E, Hsiao NY, Lesosky M, Myer L. Mobility during the post-partum period and viraemia in women living with HIV in South Africa. Int Health 2023; 15:692-701. [PMID: 36715066 PMCID: PMC10629960 DOI: 10.1093/inthealth/ihad001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 12/15/2022] [Accepted: 01/24/2023] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND We investigated the association between travel and viraemia in post-partum women with human immunodeficiency virus on antiretroviral therapy (ART). METHODS Data are from a trial of post-partum ART delivery strategies. Women who initiated ART during pregnancy, were clinically stable with a viral load (VL) <400 copies/ml and were <10 weeks post-partum were enrolled at a primary care antenatal clinic in Cape Town, South Africa. Study visits at 3, 6, 12, 18 and 24 months post-partum included questions about travel, defined as ≥1 night spent outside of the city, and VL testing. Generalised mixed effects models assessed the association between travel and subsequent VL ≥400 copies/ml. RESULTS Among 402 women (mean age 29 y, 35% born in the Western Cape), 69% reported one or more travel events over 24 months. Being born beyond the Western Cape (adjusted odds ratio [aOR] 2.03 [95% confidence interval {CI} 1.49 to 2.77]), duration post-partum in months (aOR 1.03 [95% CI 1.02 to 1.05]) and living with the child (aOR 0.60 [95% CI 0.38 to 0.93]) were associated with travel. In multivariable analyses, a travel event was associated with a 92% increase in the odds of a VL ≥400 copies/ml (aOR 1.92 [95% CI 1.19 to 3.10]). CONCLUSIONS Interventions to support women on ART who travel are urgently required.
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Affiliation(s)
- Jasantha Odayar
- Division of Epidemiology and Biostatistics, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Tamsin K Phillips
- Division of Epidemiology and Biostatistics, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Siti Kabanda
- Division of Epidemiology and Biostatistics, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Thokozile R Malaba
- Division of Epidemiology and Biostatistics, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Elton Mukonda
- Division of Epidemiology and Biostatistics, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Nei-yuan Hsiao
- Division of Medical Virology, National Health Laboratory Service, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Maia Lesosky
- Division of Epidemiology and Biostatistics, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Landon Myer
- Division of Epidemiology and Biostatistics, School of Public Health, University of Cape Town, Cape Town, South Africa
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Clouse K, Noholoza S, Madwayi S, Mrubata M, Camlin CS, Myer L, Phillips TK. The Implementation of a GPS-Based Location-Tracking Smartphone App in South Africa to Improve Engagement in HIV Care: Randomized Controlled Trial. JMIR Mhealth Uhealth 2023; 11:e44945. [PMID: 37204838 PMCID: PMC10238954 DOI: 10.2196/44945] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 03/10/2023] [Accepted: 04/21/2023] [Indexed: 05/20/2023] Open
Abstract
BACKGROUND Mobile health interventions are common in public health settings in Africa, and our preliminary work showed that smartphones are increasing in South Africa. We developed a novel smartphone app-CareConekta-that used GPS location data to characterize personal mobility to improve engagement in HIV care among pregnant and postpartum women living with HIV in South Africa. The app also used the user's location to map nearby clinics. OBJECTIVE We aimed to describe the feasibility, acceptability, and initial efficacy of using the app in a real-world setting. METHODS We conducted a prospective randomized controlled trial at a public sector clinic near Cape Town, South Africa. We enrolled 200 pregnant (third trimester) women living with HIV who owned a smartphone that met the required specifications. All participants installed the app, designed to collect 2 GPS heartbeats per day to geolocate the participant within a random 1-km fuzzy radius (for privacy). We randomized (1:1) participants to a control arm to receive the app with no additional support or an intervention arm to receive supportive phone calls, WhatsApp (Meta Platforms, Inc) messages, or both from the study team when traveling >50 km from the study area for >7 days. In addition to mobility data collected daily through the phone, participants completed questionnaires at enrollment and follow-up (approximately 6 months post partum). RESULTS A total of 7 participants were withdrawn at enrollment or shortly after because of app installation failure (6/200, 3%) or changing to an unsuitable phone (1/200, 0.50%). During the study period, no participant's smartphone recorded at least 1 heartbeat per day, which was our primary feasibility measure. Of the 171 participants who completed follow-up, only half (91/171, 53.2%) reported using the same phone as that used at enrollment, with the CareConekta app still installed on the phone and GPS usually enabled. The top reasons reported for the lack of heartbeat data were not having mobile data, uninstalling the app, and no longer having a smartphone. Acceptability measures were positive, but participants at follow-up demonstrated a lack of understanding of the app's purpose and function. The clinic finder was a popular feature. Owing to the lack of consistent GPS heartbeats throughout the study, we were unable to assess the efficacy of the intervention. CONCLUSIONS Several key challenges impeded our study feasibility. Although the app was designed to reverse bill participants for any data use, the lack of mobile data was a substantial barrier to our study success. Participants reported purchasing WhatsApp data, which could not support the app. Problems with the web-based dashboard meant that we could not consistently monitor mobility. Our study provides important lessons about implementing an ambitious GPS-based study under real-world conditions in a limited-resource setting. TRIAL REGISTRATION ClinicalTrials.gov NCT03836625; https://clinicaltrials.gov/ct2/show/NCT03836625. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) RR2-10.1186/s13063-020-4190-x.
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Affiliation(s)
- Kate Clouse
- Vanderbilt University School of Nursing, Nashville, TN, United States
- Vanderbilt Institute for Global Health, Nashville, TN, United States
| | - Sandisiwe Noholoza
- Division of Epidemiology and Biostatistics, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Sindiswa Madwayi
- Division of Epidemiology and Biostatistics, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Megan Mrubata
- Division of Epidemiology and Biostatistics, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Carol S Camlin
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, San Francisco, CA, United States
| | - Landon Myer
- Division of Epidemiology and Biostatistics, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Tamsin K Phillips
- Division of Epidemiology and Biostatistics, School of Public Health, University of Cape Town, Cape Town, South Africa
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Dzomba A, Ginsburg C, Kabudula CW, Yorlets RR, Ndagurwa P, Harawa S, Lurie MN, McGarvey ST, Tollman S, Collinson MA, White MJ, Gomez-Olive FX. Epidemiology of chronic multimorbidity and temporary migration in a rural South African community in health transition: A cross-sectional population-based analysis. FRONTIERS IN EPIDEMIOLOGY 2023; 3:1054108. [PMID: 38455922 PMCID: PMC10910947 DOI: 10.3389/fepid.2023.1054108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 03/03/2023] [Indexed: 03/09/2024]
Abstract
Introduction In sub-Saharan African settings, the increasing non-communicable disease mortality is linked to migration, which disproportionately exposes sub-populations to risk factors for co-occurring HIV and NCDs. Methods We examined the prevalence, patterns, and factors associated with two or more concurrent diagnoses of chronic diseases (i.e., multimorbidity) among temporary within-country migrants. Employing a cross-sectional design, our study sample comprised 2144 residents and non-residents 18-40 years interviewed and with measured biomarkers in 2018 in Wave 1 of the Migrant Health Follow-up Study (MHFUS), drawn from the Agincourt Health and Demographic Surveillance System (AHDSS) in rural north-eastern South Africa. We used modified Poisson regression models to estimate the association between migration status and prevalent chronic multimorbidity conditional on age, sex, education, and healthcare utilisation. Results Overall, 301 participants (14%; 95% CI 12.6-15.6), median age 31 years had chronic multimorbidity. Multimorbidity was more prevalent among non-migrants (14.6%; 95% CI 12.8-16.4) compared to migrants (12.8%; 95% CI 10.3-15.7). Non-migrants also had the greatest burden of dual-overlapping chronic morbidities, such as HIV-obesity 5.7%. Multimorbidity was 2.6 times as prevalent (PR 2.65. 95% CI 2.07-3.39) among women compared to men. Among migrants, men, and individuals with secondary or tertiary education manifested lower prevalence of two or more conditions. Discussion In a rural community with colliding epidemics, we found low but significant multimorbidity driven by a trio of conditions: HIV, hypertension, and obesity. Understanding the multimorbidity burden associated with early adulthood exposures, including potential protective factors (i.e., migration coupled with education), is a critical first step towards improving secondary and tertiary prevention for chronic disease among highly mobile marginalised sub-populations.
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Affiliation(s)
- Armstrong Dzomba
- Medical Research Council/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng Province, South Africa
| | - Carren Ginsburg
- Medical Research Council/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng Province, South Africa
| | - Chodziwadziwa W. Kabudula
- Medical Research Council/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng Province, South Africa
| | - Rachel R. Yorlets
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, United States
- Population Studies and Training Center, Brown University, Providence, RI, United States
| | - Pedzisai Ndagurwa
- South African Medical Research Council Vaccines and Infectious Diseases Analytics Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Sadson Harawa
- Medical Research Council/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng Province, South Africa
| | - Mark N. Lurie
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, United States
- Population Studies and Training Center, Brown University, Providence, RI, United States
- International Health Institute, Department of Epidemiology, School of Public Health, Brown University, Providence, RI, United States
| | - Stephen T. McGarvey
- International Health Institute, Department of Epidemiology, School of Public Health, Brown University, Providence, RI, United States
- Department of Anthropology, Brown University, Providence, RI, United States
| | - Stephen Tollman
- Medical Research Council/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng Province, South Africa
| | - Mark A. Collinson
- Medical Research Council/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng Province, South Africa
- Department of Science and Innovation/ Medical Research Council, South African Population Research Infrastructure Network, Durban, South Africa
| | - Michael J. White
- Population Studies and Training Center, Brown University, Providence, RI, United States
- Department of Sociology, Brown University, Providence, RI, United States
| | - Francesc X. Gomez-Olive
- Medical Research Council/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng Province, South Africa
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Thorp M, Bellos M, Temelkovska T, Mphande M, Cornell M, Hubbard J, Choko A, Coates TJ, Hoffman R, Dovel K. Mobility and ART retention among men in Malawi: a mixed-methods study. J Int AIDS Soc 2023; 26:e26066. [PMID: 36943753 PMCID: PMC10029992 DOI: 10.1002/jia2.26066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 01/30/2023] [Indexed: 03/23/2023] Open
Abstract
INTRODUCTION Mobility is associated with worse outcomes across the HIV treatment cascade, especially among men. However, little is known about the mechanisms that link mobility and poor HIV outcomes and what types of mobility most increase the risk of treatment interruption among men in southern Africa. METHODS From August 2021 to January 2022, we conducted a mixed-methods study with men living with HIV (MLHIV) but not currently receiving antiretroviral therapy (ART) in Malawi. Data collection was embedded within two larger trials (ENGAGE and IDEaL trials). We analysed baseline survey data of 223 men enrolled in the trials who reported being mobile (defined as spending ≥14 nights away from home in the past 12 months) using descriptive statistics and negative binomial regressions. We then recruited 32 men for in-depth interviews regarding their travel experiences and ART utilization. We analysed qualitative data using constant comparative methods. RESULTS Survey data showed that 34% of men with treatment interruptions were mobile, with a median of 60 nights away from home in the past 12 months; 69% of trips were for income generation. More nights away from home in the past 12 months and having fewer household assets were associated with longer periods out of care. In interviews, men reported that travel was often unplanned, and men were highly vulnerable to exploitive employer demands, which led to missed appointments and ART interruption. Men made major efforts to stay in care but were often unable to access care on short notice, were denied ART refills at non-home facilities and/or were treated poorly by providers, creating substantial barriers to remaining in and returning to care. Men desired additional multi-month dispensing (MMD), the ability to refill treatment at any facility in Malawi, and streamlined pre-travel refills at home facilities. CONCLUSIONS Men prioritize ART and struggle with the trade-offs between their own health and providing for their families. Mobility is an essential livelihood strategy for MLHIV in Malawi, but it creates conflict with ART retention, largely due to inflexible health systems. Targeted counselling and peer support, access to ART services anywhere in the country, and MMD may improve outcomes for mobile men.
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Affiliation(s)
- Marguerite Thorp
- Division of Infectious DiseasesDavid Geffen School of MedicineUniversity of CaliforniaLos AngelesCaliforniaUSA
| | | | - Tijana Temelkovska
- David Geffen School of MedicineUniversity of CaliforniaLos AngelesCaliforniaUSA
| | | | - Morna Cornell
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public HealthFaculty of Health SciencesUniversity of Cape TownCape TownSouth Africa
| | - Julie Hubbard
- Division of Infectious DiseasesDavid Geffen School of MedicineUniversity of CaliforniaLos AngelesCaliforniaUSA
- Partners in HopeLilongweMalawi
| | | | - Thomas J. Coates
- Division of Infectious DiseasesDavid Geffen School of MedicineUniversity of CaliforniaLos AngelesCaliforniaUSA
| | - Risa Hoffman
- Division of Infectious DiseasesDavid Geffen School of MedicineUniversity of CaliforniaLos AngelesCaliforniaUSA
| | - Kathryn Dovel
- Division of Infectious DiseasesDavid Geffen School of MedicineUniversity of CaliforniaLos AngelesCaliforniaUSA
- Partners in HopeLilongweMalawi
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Thorp M, Ayieko J, Hoffman RM, Balakasi K, Camlin CS, Dovel K. Mobility and HIV care engagement: a research agenda. J Int AIDS Soc 2023; 26:e26058. [PMID: 36943731 PMCID: PMC10029995 DOI: 10.1002/jia2.26058] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 01/10/2023] [Indexed: 03/23/2023] Open
Abstract
INTRODUCTION Mobility is common and an essential livelihood strategy in sub-Saharan Africa (SSA). Mobile people suffer worse outcomes at every stage of the HIV care cascade compared to non-mobile populations. Definitions of mobility vary widely, and research on the role of temporary mobility (as opposed to permanent migration) in HIV treatment outcomes is often lacking. In this article, we review the current landscape of mobility and HIV care research to identify what is already known, gaps in the literature, and recommendations for future research. DISCUSSION Mobility in SSA is closely linked to income generation, though caregiving, climate change and violence also contribute to the need to move. Mobility is likely to increase in the coming decades, both due to permanent migration and increased temporary mobility, which is likely much more common. We outline three central questions regarding mobility and HIV treatment outcomes in SSA. First, it is unclear what aspects of mobility matter most for HIV care outcomes and if high-risk mobility can be identified or predicted, which is necessary to facilitate targeted interventions for mobile populations. Second, it is unclear what groups are most vulnerable to mobility-associated treatment interruption and other adverse outcomes. And third, it is unclear what interventions can improve HIV treatment outcomes for mobile populations. CONCLUSIONS Mobility is essential for people living with HIV in SSA. HIV treatment programmes and broader health systems must understand and adapt to human mobility, both to promote the rights and welfare of mobile people and to end the HIV pandemic.
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Affiliation(s)
- Marguerite Thorp
- Division of Infectious DiseasesDavid Geffen School of MedicineUniversity of California Los AngelesLos AngelesCaliforniaUSA
| | - James Ayieko
- Center for Microbiology ResearchKenya Medical Research InstituteKisumuKenya
| | - Risa M. Hoffman
- Division of Infectious DiseasesDavid Geffen School of MedicineUniversity of California Los AngelesLos AngelesCaliforniaUSA
| | | | - Carol S. Camlin
- Department of ObstetricsGynecology & Reproductive SciencesUniversity of California San FranciscoSan FranciscoCaliforniaUSA
- Center for AIDS Prevention StudiesDepartment of MedicineUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | - Kathryn Dovel
- Division of Infectious DiseasesDavid Geffen School of MedicineUniversity of California Los AngelesLos AngelesCaliforniaUSA
- Partners in HopeLilongweMalawi
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Leslie HH, Mooney AC, Gilmore HJ, Agnew E, Grignon JS, deKadt J, Shade SB, Ratlhagana MJ, Sumitani J, Barnhart S, Steward WT, Lippman SA. Prevalence, motivation, and outcomes of clinic transfer in a clinical cohort of people living with HIV in North West Province, South Africa. BMC Health Serv Res 2022; 22:1584. [PMID: 36572869 PMCID: PMC9791728 DOI: 10.1186/s12913-022-08962-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 12/13/2022] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION Continuity of care is an attribute of high-quality health systems and a necessary component of chronic disease management. Assessment of health information systems for HIV care in South Africa has identified substantial rates of clinic transfer, much of it undocumented. Understanding the reasons for changing sources of care and the implications for patient outcomes is important in informing policy responses. METHODS In this secondary analysis of the 2014 - 2016 I-Care trial, we examined self-reported changes in source of HIV care among a cohort of individuals living with HIV and in care in North West Province, South Africa. Individuals were enrolled in the study within 1 year of diagnosis; participants completed surveys at 6 and 12 months including items on sources of care. Clinical data were extracted from records at participants' original clinic for 12 months following enrollment. We assessed frequency and reason for changing clinics and compared the demographics and care outcomes of those changing and not changing source of care. RESULTS Six hundred seventy-five (89.8%) of 752 study participants completed follow-up surveys with information on sources of HIV care; 101 (15%) reported receiving care at a different facility by month 12 of follow-up. The primary reason for changing was mobility (N=78, 77%). Those who changed clinics were more likely to be young adults, non-citizens, and pregnant at time of diagnosis. Self-reported clinic attendance and ART adherence did not differ based on changing clinics. Those on ART not changing clinics reported 0.66 visits more on average than were documented in clinic records. CONCLUSION At least 1 in 6 participants in HIV care changed clinics within 2 years of diagnosis, mainly driven by mobility; while most appeared lost to follow-up based on records from the original clinic, self-reported visits and adherence were equivalent to those not changing clinics. Routine clinic visits could incorporate questions about care at other locations as well as potential relocation, particularly for younger, pregnant, and non-citizen patients, to support existing efforts to make HIV care records portable and facilitate continuity of care across clinics. TRIAL REGISTRATION The original trial was registered with ClinicalTrials.gov , NCT02417233, on 12 December 2014.
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Affiliation(s)
- Hannah H. Leslie
- Division of Prevention Science, Department of Medicine, University of California, San Francisco, 550 16th Street, San Francisco, CA 94158 USA
| | - Alyssa C. Mooney
- Institute for Health Policy Studies, University of California, San Francisco, San Francisco, CA USA
| | - Hailey J. Gilmore
- Division of Prevention Science, Department of Medicine, University of California, San Francisco, 550 16th Street, San Francisco, CA 94158 USA
| | - Emily Agnew
- Division of Prevention Science, Department of Medicine, University of California, San Francisco, 550 16th Street, San Francisco, CA 94158 USA
| | - Jessica S. Grignon
- Department of Global Health, University of Washington, Seattle, WA USA
- International Training and Education Center for Health (I-TECH) South Africa, Pretoria, Republic of South Africa
| | - Julia deKadt
- International Training and Education Center for Health (I-TECH) South Africa, Pretoria, Republic of South Africa
| | - Starley B. Shade
- Division of Prevention Science, Department of Medicine, University of California, San Francisco, 550 16th Street, San Francisco, CA 94158 USA
| | - Mary Jane Ratlhagana
- International Training and Education Center for Health (I-TECH) South Africa, Pretoria, Republic of South Africa
| | - Jeri Sumitani
- International Training and Education Center for Health (I-TECH) South Africa, Pretoria, Republic of South Africa
| | - Scott Barnhart
- Department of Global Health, University of Washington, Seattle, WA USA
| | - Wayne T. Steward
- Division of Prevention Science, Department of Medicine, University of California, San Francisco, 550 16th Street, San Francisco, CA 94158 USA
| | - Sheri A. Lippman
- Division of Prevention Science, Department of Medicine, University of California, San Francisco, 550 16th Street, San Francisco, CA 94158 USA
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Murphy JP, Shumba K, Jamieson L, Nattey C, Pascoe S, Fox MP, Miot J, Maskew M. Assessment of facility-level antiretroviral treatment patient status utilizing a national-level laboratory cohort: Toward an understanding of system-level tracking and clinic switching in South Africa. Front Public Health 2022; 10:959481. [PMID: 36590005 PMCID: PMC9798405 DOI: 10.3389/fpubh.2022.959481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 11/11/2022] [Indexed: 12/23/2022] Open
Abstract
Background Most estimates of HIV retention are derived at the clinic level through antiretroviral (ART) patient management systems, which capture ART clinic visit data, yet these cannot account for silent transfers across HIV treatment sites. Patient laboratory monitoring visits may also be observed in routinely collected laboratory data, which include ART monitoring tests such as CD4 count and HIV viral load, key to our work here. Methods In this analysis, we utilized the NHLS National HIV Cohort (a system-wide viewpoint) to investigate the accuracy of facility-level estimates of retention in care for adult patients accessing care (defined using clinic visit data on patients under ART recorded in an electronic patient management system) at Themba Lethu Clinic (TLC). Furthermore, we describe patterns of facility switching among all patients and those patients classified as lost to follow-up (LTFU) at the facility level. Results Of the 43,538 unique patients in the TLC dataset, we included 20,093 of 25,514 possible patient records (78.8%) in our analysis that were linked with the NHLS National Cohort, and we restricted the analytic sample to patients initiating ART between 1 January 2007 and 31 December 2017. Most (60%) patients were female, and the median age (IQR) at ART initiation was 37 (31-45) years. We found the laboratory records augmented retention estimates by a median of 860 additional active records (about 8% of all median active records across all years) from the facility viewpoint; this augmentation was more noticeable from the system-wide viewpoint, which added evidence of activity of about one-third of total active records in 2017. In 2017, we found 7.0% misclassification at the facility-level viewpoint, a gap which is potentially solvable through data integration/triangulation. We observed 1,134/20,093 (5.6%) silent transfers; these were noticeably more female and younger than the entire dataset. We also report the most common locations for clinic switching at a provincial level. Discussion Integration of multiple data sources has the potential to reduce the misclassification of patients as being lost to care and help understand situations where clinic switching is common. This may help in prioritizing interventions that would assist patients moving between clinics and hopefully contribute to services that normalize formal transfers and fewer silent transfers.
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Affiliation(s)
- Joshua P. Murphy
- Health Economics and Epidemiology Research Office (HERO), Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa,*Correspondence: Joshua P. Murphy
| | - Khumbo Shumba
- Health Economics and Epidemiology Research Office (HERO), Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Lise Jamieson
- Health Economics and Epidemiology Research Office (HERO), Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Cornelius Nattey
- Health Economics and Epidemiology Research Office (HERO), Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Sophie Pascoe
- Health Economics and Epidemiology Research Office (HERO), Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Matthew P. Fox
- Health Economics and Epidemiology Research Office (HERO), Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa,Department of Global Health, School of Public Health, Boston University, Boston, MA, United States
| | - Jacqui Miot
- Health Economics and Epidemiology Research Office (HERO), Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mhairi Maskew
- Health Economics and Epidemiology Research Office (HERO), Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Improved virologic outcomes in postpartum women living with HIV referred to differentiated models of care. AIDS 2022; 36:2203-2211. [PMID: 36111547 DOI: 10.1097/qad.0000000000003385] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Differentiated service delivery (DSD) models are used to deliver antiretroviral therapy (ART) but data are limited in postpartum women, who are at high risk of non-adherence and elevated viral load (VL) over the extended postpartum period. DESIGN Randomized controlled trial. METHODS We enrolled consecutive postpartum women who initiated ART during pregnancy and met local DSD eligibility (clinically stable, VL less than 400 copies/ml) at a large primary healthcare (PHC) clinic. Women were randomized to a community-based 'adherence club' (AC, the local DSD model: community health worker-led groups of 20-30 patients with ART dispensing at a community venue) or routine PHC clinics (local standard of care with nurse/doctor-led services). Follow-up visits with VL separate from routine care took place at 3, 6, 12, 18 and 24 months postpartum. Endpoints were time to VL of at least 1000 copies/ml (primary) and VL of at least 50 copies/ml (secondary) by intention-to-treat. RESULTS At enrolment ( n = 409), the median duration postpartum was 10 days, all women had a VL less than 1000 copies/ml and 88% had a VL less than 50 copies/ml; baseline characteristics did not differ by arm. Twenty-four-month retention was 89%. Sixteen and 29% of women in AC experienced a VL of at least 1000 copies/ml by 12 and 24 months, compared to 23 and 37% in PHC, respectively (hazard ratio [HR] = 0.71; 95% confidence interval [CI] = 0.50-1.01). Thirty-two and 44% of women in ACs had a VL of at least 50 copies/ml by 12 and 24 months, compared to 42 and 56% in PHC, respectively (HR = 0.68; 95% CI = 0.51-0.91). CONCLUSIONS Early DSD referral was associated with reduced viraemia through 24 months postpartum and may be an important strategy to improve maternal virologic outcomes.
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Clouse K, Noholoza S, Ngcobo N, Madwayi S, Mrubata M, Camlin CS, Myer L, Phillips TK. Cohort profile: CareConekta: a pilot study of a smartphone application to improve engagement in postpartum HIV care in South Africa. BMJ Open 2022; 12:e064946. [PMID: 36414286 PMCID: PMC9685000 DOI: 10.1136/bmjopen-2022-064946] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 10/30/2022] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Pregnant and postpartum women living with HIV in South Africa are at high risk of dropping out of care, particularly after delivery. Population mobility may contribute to disruptions in HIV care, and postpartum women are known to be especially mobile. To improve engagement in HIV care during the peripartum period, we developed CareConekta, a smartphone application (app) that uses GPS coordinates to characterise mobility and allow for real-time intervention. We conducted a randomised controlled pilot study to assess feasibility, acceptability and initial efficacy of the app intervention to improve engagement in HIV care. This cohort profile describes participant enrolment and follow-up, describes the data collected and provides participant characteristics. PARTICIPANTS We enrolled 200 pregnant women living with HIV attending routine antenatal care at the Gugulethu Midwife Obstetric Unit in Cape Town, South Africa. Eligible women must have owned smartphones that met the app's technical requirements. Seven participants were withdrawn near enrolment, leaving 193 in the cohort. FINDINGS TO DATE Data were collected from detailed participant questionnaires at enrolment and follow-up (6 months after delivery), as well as GPS data from the app, and medical records. Follow-up is complete; initial analyses have explored smartphone ownership, preferences and patterns of use among women screened for eligibility and those enrolled in the study. FUTURE PLANS Additional planned analyses will characterise mobility in the population using the phone GPS data and participant self-reported data. We will assess the impact of mobility on engagement in care for the mother and infant. We also will describe the acceptability and feasibility of the study, including operational lessons learnt. By linking this cohort to the National Health Laboratory Service National HIV Cohort in South Africa, we will continue to assess engagement in care and mobility outcomes for years to come. Collaborations are welcome. TRIAL REGISTRATION NUMBER NCT03836625.
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Affiliation(s)
- Kate Clouse
- Vanderbilt University School of Nursing, Nashville, TN, USA
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sandisiwe Noholoza
- Division of Epidemiology and Biostatistics, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Nkosinathi Ngcobo
- Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Sindiswa Madwayi
- Division of Epidemiology and Biostatistics, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Megan Mrubata
- Division of Epidemiology and Biostatistics, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Carol S Camlin
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California San Francisco, San Francisco, California, USA
| | - Landon Myer
- Division of Epidemiology and Biostatistics, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Tamsin K Phillips
- Division of Epidemiology and Biostatistics, School of Public Health, University of Cape Town, Cape Town, South Africa
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Keene CM, Ragunathan A, Euvrard J, English M, McKnight J, Orrell C. Measuring patient engagement with HIV care in sub-Saharan Africa: a scoping study. J Int AIDS Soc 2022; 25:e26025. [PMID: 36285618 PMCID: PMC9597383 DOI: 10.1002/jia2.26025] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 09/27/2022] [Indexed: 11/05/2022] Open
Abstract
INTRODUCTION Engagement with HIV care is a multi-dimensional, dynamic process, critical to maintaining successful treatment outcomes. However, measures of engagement are not standardized nor comprehensive. This undermines our understanding of the scope of challenges with engagement and whether interventions have an impact, complicating patient and programme-level decision-making. This study identified and characterized measures of engagement to support more consistent and comprehensive evaluation. METHODS We conducted a scoping study to systematically categorize measures the health system could use to evaluate engagement with HIV care for those on antiretroviral treatment. Key terms were used to search literature databases (Embase, PsychINFO, Ovid Global-Health, PubMed, Scopus, CINAHL, Cochrane and the World Health Organization Index Medicus), Google Scholar and stakeholder-identified manuscripts, ultimately including English evidence published from sub-Saharan Africa from 2014 to 2021. Measures were extracted, organized, then reviewed with key stakeholders. RESULTS AND DISCUSSION We screened 14,885 titles/abstracts, included 118 full-texts and identified 110 measures of engagement, categorized into three engagement dimensions ("retention," "adherence" and "active self-management"), a combination category ("multi-dimensional engagement") and "treatment outcomes" category (e.g. viral load as an end-result reflecting that engagement occurred). Retention reflected status in care, continuity of attendance and visit timing. Adherence was assessed by a variety of measures categorized into primary (prescription not filled) and secondary measures (medication not taken as directed). Active self-management reflected involvement in care and self-management. Three overarching use cases were identified: research to make recommendations, routine monitoring for quality improvement and strategic decision-making and assessment of individual patients. CONCLUSIONS Heterogeneity in conceptualizing engagement with HIV care is reflected by the broad range of measures identified and the lack of consensus on "gold-standard" indicators. This review organized metrics into five categories based on the dimensions of engagement; further work could identify a standardized, minimum set of measures useful for comprehensive evaluation of engagement for different use cases. In the interim, measurement of engagement could be advanced through the assessment of multiple categories for a more thorough evaluation, conducting sensitivity analyses with commonly used measures for more comparable outputs and using longitudinal measures to evaluate engagement patterns. This could improve research, programme evaluation and nuanced assessment of individual patient engagement in HIV care.
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Affiliation(s)
- Claire M. Keene
- Health Systems CollaborativeOxford Centre for Global Health ResearchNuffield Department of MedicineUniversity of OxfordOxfordUnited Kingdom
| | - Ayesha Ragunathan
- Health Systems CollaborativeOxford Centre for Global Health ResearchNuffield Department of MedicineUniversity of OxfordOxfordUnited Kingdom
| | - Jonathan Euvrard
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public Health and Family MedicineFaculty of Health SciencesUniversity of Cape TownCape TownSouth Africa
| | - Mike English
- Health Systems CollaborativeOxford Centre for Global Health ResearchNuffield Department of MedicineUniversity of OxfordOxfordUnited Kingdom
| | - Jacob McKnight
- Health Systems CollaborativeOxford Centre for Global Health ResearchNuffield Department of MedicineUniversity of OxfordOxfordUnited Kingdom
| | - Catherine Orrell
- Department of MedicineFaculty of Health SciencesUniversity of Cape TownCape TownSouth Africa
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Keene CM, Ragunathan A, Euvrard J, English M, McKnight J, Orrell C. Measuring patient engagement with HIV care in sub-Saharan Africa: a scoping study. J Int AIDS Soc 2022; 25:e26025. [PMID: 36285618 PMCID: PMC9597383 DOI: 10.1002/jia2.26025/full|10.1002/jia2.26025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 09/27/2022] [Indexed: 05/22/2023] Open
Abstract
INTRODUCTION Engagement with HIV care is a multi-dimensional, dynamic process, critical to maintaining successful treatment outcomes. However, measures of engagement are not standardized nor comprehensive. This undermines our understanding of the scope of challenges with engagement and whether interventions have an impact, complicating patient and programme-level decision-making. This study identified and characterized measures of engagement to support more consistent and comprehensive evaluation. METHODS We conducted a scoping study to systematically categorize measures the health system could use to evaluate engagement with HIV care for those on antiretroviral treatment. Key terms were used to search literature databases (Embase, PsychINFO, Ovid Global-Health, PubMed, Scopus, CINAHL, Cochrane and the World Health Organization Index Medicus), Google Scholar and stakeholder-identified manuscripts, ultimately including English evidence published from sub-Saharan Africa from 2014 to 2021. Measures were extracted, organized, then reviewed with key stakeholders. RESULTS AND DISCUSSION We screened 14,885 titles/abstracts, included 118 full-texts and identified 110 measures of engagement, categorized into three engagement dimensions ("retention," "adherence" and "active self-management"), a combination category ("multi-dimensional engagement") and "treatment outcomes" category (e.g. viral load as an end-result reflecting that engagement occurred). Retention reflected status in care, continuity of attendance and visit timing. Adherence was assessed by a variety of measures categorized into primary (prescription not filled) and secondary measures (medication not taken as directed). Active self-management reflected involvement in care and self-management. Three overarching use cases were identified: research to make recommendations, routine monitoring for quality improvement and strategic decision-making and assessment of individual patients. CONCLUSIONS Heterogeneity in conceptualizing engagement with HIV care is reflected by the broad range of measures identified and the lack of consensus on "gold-standard" indicators. This review organized metrics into five categories based on the dimensions of engagement; further work could identify a standardized, minimum set of measures useful for comprehensive evaluation of engagement for different use cases. In the interim, measurement of engagement could be advanced through the assessment of multiple categories for a more thorough evaluation, conducting sensitivity analyses with commonly used measures for more comparable outputs and using longitudinal measures to evaluate engagement patterns. This could improve research, programme evaluation and nuanced assessment of individual patient engagement in HIV care.
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Affiliation(s)
- Claire M. Keene
- Health Systems CollaborativeOxford Centre for Global Health ResearchNuffield Department of MedicineUniversity of OxfordOxfordUnited Kingdom
| | - Ayesha Ragunathan
- Health Systems CollaborativeOxford Centre for Global Health ResearchNuffield Department of MedicineUniversity of OxfordOxfordUnited Kingdom
| | - Jonathan Euvrard
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public Health and Family MedicineFaculty of Health SciencesUniversity of Cape TownCape TownSouth Africa
| | - Mike English
- Health Systems CollaborativeOxford Centre for Global Health ResearchNuffield Department of MedicineUniversity of OxfordOxfordUnited Kingdom
| | - Jacob McKnight
- Health Systems CollaborativeOxford Centre for Global Health ResearchNuffield Department of MedicineUniversity of OxfordOxfordUnited Kingdom
| | - Catherine Orrell
- Department of MedicineFaculty of Health SciencesUniversity of Cape TownCape TownSouth Africa
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Temporal changes in paediatric and adolescent HIV outcomes across the care continuum in Zambia: an interrupted time-series analysis. THE LANCET HIV 2022; 9:e563-e573. [PMID: 35905754 PMCID: PMC9394542 DOI: 10.1016/s2352-3018(22)00127-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Revised: 04/13/2022] [Accepted: 04/22/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Paediatric and adolescent HIV treatment programmes in sub-Saharan Africa have rapidly expanded and evolved over the past decade. Real-world evidence of how the implementation of new policies over time has affected treatment outcomes is inadequate, but is crucial for guiding the implementation of the next phases of the HIV treatment response for children. We examined how treatment outcomes in Zambia's national paediatric and adolescent HIV treatment programmes have changed over time as new policies were implemented. METHODS We used data from Zambia's routine electronic health record to analyse children and adolescents living with HIV who were antiretroviral therapy (ART) naive between the ages of 0 and 19 years who were newly enrolled in care between Jan 1, 2011, and March 31, 2019, at 102 health facilities in Lusaka and Western provinces supported by the Centre for Infectious Disease Research in Zambia. Sociodemographic factors, clinical data, facility-level data, and visit history were obtained from the national electronic health record and laboratory systems used in routine HIV care in Zambia. We aimed to characterise the changes in the distribution of the age and sex of new enrolees over time. We used an interrupted time-series design to examine the rates of ART initiation, retention in care, time to ART initiation, and first-line ART regimens among new enrolees across different age strata as they changed over time with the adoption of new ART guidelines in 2014 and 2017. FINDINGS Between Jan 1, 2011, and March 31, 2019, 26 214 children and adolescents living with HIV who were ART naïve were newly enrolled at one of 102 ART facilities in two provinces in Zambia. Rates of new enrolees increased by 25-35% among children younger than 15 years over time, but by 92·3% between 2011 and 2017 among adolescents, with the largest absolute increase among adolescent girls. Rates of ART initiation increased steadily and in parallel across all age groups from before the implementation of the 2014 guidelines to after the implementation of the 2017 guidelines (<2 years, 42·4% for 2014 and 81·6% for 2017; 2 to <5 years, 39·3% for 2014 and 82·8% for 2017; 5 to <15 years, 49·2% for 2014 and 86·6% for 2017; 15 to 19 years, 52·4% for 2014 and 86·2% for 2017); median time to ART initiation went from 2-3 months to same-day initiation during this same time period. Rates of retention on ART 6 months after linkage saw much smaller improvements over time (<2 years, 35·4% for 2014 and 52·0% for 2017; 2 to <5 years, 40·2% for 2014 and 54·4% for 2017; 5 to <15 years, 46·7% for 2014 and 63·4% for 2017; 15 to 19 years, 40·1% for 2014 and 52·7% for 2017). INTERPRETATION Improvements in ART initiation occurred largely in parallel across age groups over time, despite universal treatment being implemented at different timepoints for different ages. Although the rates of ART initiation reach high levels, retention on ART was low. This analysis provides a comprehensive examination of how paediatric and adolescent outcomes have evolved over the past decade in Zambia and identifies where more targeted efforts will be needed over the next decade. FUNDING National Institutes of Health.
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21
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Odayar J, Chi BH, Phillips TK, Mukonda E, Hsiao NY, Lesosky M, Myer L. Transfer of Patients on Antiretroviral Therapy Attending Primary Health Care Services in South Africa. J Acquir Immune Defic Syndr 2022; 90:309-315. [PMID: 35298449 DOI: 10.1097/qai.0000000000002950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 02/22/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Patients stable on antiretroviral therapy (ART) may require transfer between health care facilities to maintain continuous care, yet data on the frequency, predictors, and virologic outcomes of transfers are limited. METHODS Data for all viral load (VL) testing at public sector health facilities in the Western Cape Province (2011-2018) were obtained. Participant inclusion criteria were a first VL between 2011 and 2013, age >15 years at ART initiation, and >1 VL within 5 years of ART initiation, of which ≥1 was at a primary health care facility. Two successive VLs taken at different facilities indicated a transfer. We assessed predictors of transfer using generalized estimating equations with Poisson regression and the association between transfer and subsequent VL> 1000 copies/mL using generalized mixed effects. RESULTS Overall 84,814 participants (median age at ART initiation 34 years and 68% female) were followed up for up to 4.5 years after their first VL: 34% (n = 29,056) transferred at least once, and among these, 26% transferred twice and 11% transferred thrice or more. Female sex, age <30 years, and first VL > 1000 copies/mL were independently associated with an increased rate of transfer [adjusted rate ratio 1.24, 95% confidence interval (CI): 1.21 to 1.26; 1.34, 95% CI: 1.31 to 1.36; and 1.42, 95% CI: 1.38 to 1.45, respectively]. Adjusting for age, sex, and disengagement, transfer was associated with an increased relative odds of VL > 1000 copies/mL (odds ratio 1.35, 95% CI: 1.29 to 1.42). CONCLUSIONS Approximately one-third of participants transferred and virologic outcomes were poor post-transfer. Stable patients who transfer may require additional support to maintain adherence.
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Affiliation(s)
- Jasantha Odayar
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Benjamin H Chi
- Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC; and
| | - Tamsin K Phillips
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Elton Mukonda
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Nei-Yuan Hsiao
- Division of Medical Virology, National Health Laboratory Service, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Maia Lesosky
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Landon Myer
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
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Dzomba A, Kim HY, Tomita A, Vandormael A, Govender K, Tanser F. Predictors of migration in an HIV hyper-endemic rural South African community: evidence from a population-based cohort (2005-2017). BMC Public Health 2022; 22:1141. [PMID: 35672845 PMCID: PMC9175358 DOI: 10.1186/s12889-022-13526-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 05/23/2022] [Indexed: 11/16/2022] Open
Abstract
Globally, South Africa hosts the highest number of people living with HIV (PLHIV) and the unique legacy of internal labour migration continues to be a major driver of the regional epidemic, interrupting treatment-as-prevention efforts. The study examined levels, trends, and predictors of migration in rural KwaZulu-Natal Province, South Africa, using population-based surveillance data from 2005 through 2017. We followed 69 604 adult participants aged 15-49 years and recorded their migration events (i.e., out-migration from the surveillance area) in 423 038 person-years over 525 397 observations. Multiple failure Cox-regression models were used to measure the risk of migration by socio-demographic factors: age, sex, educational status, marital status, HIV, and community antiretroviral therapy (ART) coverage. Overall, 69% of the population cohort experienced at least one migration event during the follow-up period. The average incidence rate of migration was 9.96 events and 13.23 events per 100 person-years in women and men, respectively. Migration rates declined from 2005 to 2008 then peaked in 2012 for both women and men. Adjusting for other covariates, the risk of migration was 3.4-times higher among young women aged 20-24 years compared to those aged ≥ 40 years (adjusted Hazard Ratio [aHR] = 3.37, 95% Confidence Interval [CI]: 3:19-3.57), and 2.9-times higher among young men aged 20-24 years compared to those aged ≥ 40 years (aHR = 2.86, 95% CI:2.69-3.04). There was a 9% and 27% decrease in risk of migration among both women (aHR = 0.91, 95% CI: 0.83 - 0.99) and men (aHR = 0.73, 95% CI 0.66 - 0.82) respectively per every 1% increase in community ART coverage. Young unmarried women including those living with HIV, migrated at a magnitude similar to that of their male counterparts, and lowered as ART coverage increased over time, reflecting the role of improved HIV services across space in reducing out-migration. A deeper understanding of the characteristics of a migrating population provides critical information towards identifying and addressing gaps in the HIV prevention and care continuum in an era of high mobility.
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Affiliation(s)
- Armstrong Dzomba
- Discipline of Public Health Medicine, Africa Health Research Institute(AHRI), University of KwaZulu-Natal, KwaZulu-Natal Province, K-RITH Tower Building, 719 Umbilo Road, Private Bag X7, Congella, Durban, South Africa.
- KwaZulu-Natal Research Innovation and Sequencing Platform (KRISP), University of KwaZulu-Natal, Durban, South Africa.
- Medical Research Council (MRC)/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), University of the Witwatersrand, Acornhoek, South Africa.
| | - Hae-Young Kim
- Discipline of Public Health Medicine, Africa Health Research Institute(AHRI), University of KwaZulu-Natal, KwaZulu-Natal Province, K-RITH Tower Building, 719 Umbilo Road, Private Bag X7, Congella, Durban, South Africa
- Department of Population Health, New York University Grossman School of Medicine, New York City, NY, USA
| | - Andrew Tomita
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Alain Vandormael
- Heidelberg Institute of Global Health (HIGH), University of Heidelberg, Heidelberg, Germany
- Department of Medicine, Stanford University, Stanford, USA
| | - Kaymarlin Govender
- Health Economics and HIV and AIDS Research Division (HEARD), University of KwaZulu-Natal, Durban, South Africa
| | - Frank Tanser
- Discipline of Public Health Medicine, Africa Health Research Institute(AHRI), University of KwaZulu-Natal, KwaZulu-Natal Province, K-RITH Tower Building, 719 Umbilo Road, Private Bag X7, Congella, Durban, South Africa
- Centre for Rural Health, 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, Durban, South Africa
- Lincoln Institute for Health, University of Lincoln, Lincoln, LN6 7TS, UK
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Retention in care and viral suppression in the PMTCT continuum at a large referral facility in western Kenya. AIDS Behav 2022; 26:3494-3505. [PMID: 35467229 PMCID: PMC9550706 DOI: 10.1007/s10461-022-03666-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/18/2022] [Indexed: 11/20/2022]
Abstract
Medical records of pregnant and postpartum women living with HIV and their infants attending a large referral facility in Kenya from 2015 to 2019 were analyzed to identify characteristics associated with retention in care and viral suppression. Women were stratified based on the timing of HIV care enrollment: known HIV-positive (KHP; enrolled pre-pregnancy) and newly HIV-positive (NHP; enrolled during pregnancy). Associations with retention at 18 months postpartum and viral suppression (< 1000 copies/mL) were determined. Among 856 women (20% NHP), retention was 83% for KHPs and 53% for NHPs. Viral suppression was 88% for KHPs and 93% for NHPs, but 19% of women were missing viral load results. In a competing risk model, viral suppression increased by 18% for each additional year of age but was not associated with other factors. Overall, 1.9% of 698 infants with ≥ 1 HIV test result were HIV-positive. Tailored interventions are needed to promote retention and viral load testing, particularly for NHPs, in the PMTCT continuum.
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Spooner E, Reddy T, Mchunu N, Reddy S, Daniels B, Ngomane N, Luthuli N, Kiepiela P, Coutsoudis A. Point-of-care CD4 testing: Differentiated care for the most vulnerable. J Glob Health 2022; 12:04004. [PMID: 35136596 PMCID: PMC8818294 DOI: 10.7189/jogh.12.04004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background South Africa, with the highest burden of HIV infection globally, has made huge strides in its HIV/ART programme, but AIDS deaths have not decreased proportionally to ART uptake. Advanced HIV disease (CD4 < 200 cells/mm3) persists, and CD4 count testing is being overlooked since universal test-and-treat was implemented. Point-of-care CD4 testing could address this gap and assure differentiated care to these vulnerable patients with low CD4 counts. Methods A time randomised implementation trial was conducted, enrolling 603 HIV positive non-ART, not pregnant patients at a primary health care clinic in Durban, South Africa. Weeks were randomised to either point-of-care CD4 testing (n = 305 patients) or standard-of-care central laboratory CD4 testing (n = 298 patients) to assess the proportion initiating ART at 3 months. Cox regression, with robust standard errors adjusting for clustering by week, were used to assess the relationship between treatment initiation and arm. Results Among the 578 (299 point-of-care and 279 standard-of-care) patients eligible for analysis, there was no significant difference in the number of eligible patients initiating ART within 3 months in the point-of-care (73%) and the standard-of-care (68%) groups (P = 0.112). The time-to-treat analysis was not significantly different in patients with CD4 counts of 201-500 cells/mm3 which could have been due to appointment scheduling to cope with the large burden of cases. However, in patients with advanced HIV disease (CD4 < 200cells/mm3) 65% more patients started ART earlier in the point-of-care group (HR 1.65 (95% confidence interval (CI) = 0.99-2.75; P = 0.052) compared to the standard-of-care group. Conclusions Point-of-care testing decreased time-to-treatment in those with advanced HIV disease. With universal test and treat for HIV, rollout of simple point-of-care CD4 testing would ensure early diagnosis of advanced HIV disease and facilitate differentiated care for these vulnerable patients as per the World Health Organisation 2020 target product profile for point-of-care CD4 testing. Trial registration ISRCTN14220457.
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Affiliation(s)
- Elizabeth Spooner
- Department of Paediatrics and Child Health, University of KwaZulu-Natal, Durban, South Africa
- South African Medical Research Council, HIV Prevention Research Unit, Durban, South Africa
| | - Tarylee Reddy
- South African Medical Research Council, Biostatistics Unit, Durban, South Africa
| | - Nobuhle Mchunu
- South African Medical Research Council, Biostatistics Unit, Durban, South Africa
- School of Mathematics, Statistics and Computer Science, University of KwaZulu-Natal, Pietermaritzburg, South Africa
| | | | - Brodie Daniels
- South African Medical Research Council, HIV Prevention Research Unit, Durban, South Africa
| | | | | | | | - Anna Coutsoudis
- Department of Paediatrics and Child Health, University of KwaZulu-Natal, Durban, South Africa
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Etoori D, Kabudula CW, Wringe A, Rice B, Renju J, Gomez-Olive FX, Reniers G. Investigating clinic transfers among HIV patients considered lost to follow-up to improve understanding of the HIV care cascade: Findings from a cohort study in rural north-eastern South Africa. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000296. [PMID: 36962304 PMCID: PMC10022370 DOI: 10.1371/journal.pgph.0000296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Accepted: 05/02/2022] [Indexed: 11/18/2022]
Abstract
Investigating clinical transfers of HIV patients is important for accurate estimates of retention and informing interventions to support patients. We investigate transfers for adults reported as lost to follow-up (LTFU) from eight HIV care facilities in the Agincourt health and demographic surveillance system (HDSS), South Africa. Using linked clinic and HDSS records, outcomes of adults more than 90 days late for their last scheduled clinic visit were determined through clinic and routine tracing record reviews, HDSS data, and supplementary tracing. Factors associated with transferring to another clinic were determined through Cox regression models. Transfers were graphically and geospatially visualised. Transfers were more common for women, patients living further from the clinic, and patients with higher baseline CD4 cell counts. Transfers to clinics within the HDSS were more likely to be undocumented and were significantly more likely for women pregnant at ART initiation. Transfers outside the HDSS clustered around economic hubs. Patients transferring to health facilities within the HDSS may be shopping for better care, whereas those who transfer out of the HDSS may be migrating for work. Treatment programmes should facilitate transfer processes for patients, ensure continuity of care among those migrating, and improve tracking of undocumented transfers.
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Affiliation(s)
- David Etoori
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Chodziwadziwa Whiteson Kabudula
- MRC/WITS Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of Witwatersrand, Johannesburg, South Africa
| | - Alison Wringe
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Brian Rice
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Jenny Renju
- London School of Hygiene and Tropical Medicine, London, United Kingdom
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Francesc Xavier Gomez-Olive
- MRC/WITS Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of Witwatersrand, Johannesburg, South Africa
| | - Georges Reniers
- London School of Hygiene and Tropical Medicine, London, United Kingdom
- MRC/WITS Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of Witwatersrand, Johannesburg, South Africa
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Oluoch T, Cornet R, Muthusi J, Katana A, Kimanga D, Kwaro D, Okeyo N, Abu-Hanna A, de Keizer N. A clinical decision support system is associated with reduced loss to follow-up among patients receiving HIV treatment in Kenya: a cluster randomized trial. BMC Med Inform Decis Mak 2021; 21:357. [PMID: 34930228 PMCID: PMC8686234 DOI: 10.1186/s12911-021-01718-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 12/12/2021] [Indexed: 11/13/2022] Open
Abstract
Background Loss to follow-up (LFTU) among HIV patients remains a major obstacle to achieving treatment goals with the risk of failure to achieve viral suppression and thereby increased HIV transmission. Although use of clinical decision support systems (CDSS) has been shown to improve adherence to HIV clinical guidance, to our knowledge, this is among the first studies conducted to show its effect on LTFU in low-resource settings. Methods We analyzed data from a cluster randomized controlled trial in adults and children (aged ≥ 18 months) who were receiving antiretroviral therapy at 20 HIV clinics in western Kenya between Sept 1, 2012 and Jan 31, 2014. Participating clinics were randomly assigned, via block randomization. Clinics in the control arm had electronic health records (EHR) only while the intervention arm had an EHR with CDSS. The study objectives were to assess the effects of a CDSS, implemented as alerts on an EHR system, on: (1) the proportion of patients that were LTFU, (2) LTFU patients traced and successfully linked back to treatment, and (3) time from enrollment on the study to documentation of LTFU. Results Among 5901 eligible patients receiving ART, 40.6% (n = 2396) were LTFU during the study period. CDSS was associated with lower LTFU among the patients (Adjusted Odds Ratio—aOR 0.70 (95% CI 0.65–0.77)). The proportions of patients linked back to treatment were 25.8% (95% CI 21.5–25.0) and 30.6% (95% CI 27.9–33.4)) in EHR only and EHR with CDSS sites respectively. CDSS was marginally associated with reduced time from enrollment on the study to first documentation of LTFU (adjusted Hazard Ratio—aHR 0.85 (95% CI 0.78–0.92)). Conclusion A CDSS can potentially improve quality of care through reduction and early detection of defaulting and LTFU among HIV patients and their re-engagement in care in a resource-limited country. Future research is needed on how CDSS can best be combined with other interventions to reduce LTFU. Trial registration NCT01634802. Registered at www.clinicaltrials.gov on 12-Jul-2012. Registered prospectively.
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Affiliation(s)
- Tom Oluoch
- Division of Global HIV and TB, US Centers for Disease Control and Prevention, 1600 Clifton Road NE, GA, 30329, Atlanta, USA.
| | - Ronald Cornet
- Department of Medical Informatics, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jacques Muthusi
- Division of Global HIV and TB, US Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Abraham Katana
- Division of Global HIV and TB, US Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Davies Kimanga
- Division of Global HIV and TB, US Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Daniel Kwaro
- Kenya Medical Research Institute - CDC Collaborative Program, Kisumu, Kenya
| | - Nicky Okeyo
- Kenya Medical Research Institute - CDC Collaborative Program, Kisumu, Kenya
| | - Ameen Abu-Hanna
- Department of Medical Informatics, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Nicolette de Keizer
- Department of Medical Informatics, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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Phillips TK, Olsen H, Teasdale CA, Geller A, Ts’oeu M, Buono N, Kayira D, Ngeno B, Modi S, Abrams EJ. Uninterrupted HIV treatment for women: Policies and practices for care transitions during pregnancy and breastfeeding in Côte d'Ivoire, Lesotho and Malawi. PLoS One 2021; 16:e0260530. [PMID: 34855814 PMCID: PMC8638956 DOI: 10.1371/journal.pone.0260530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 11/11/2021] [Indexed: 12/03/2022] Open
Abstract
Transitions between services for continued antiretroviral treatment (ART) during and after pregnancy are a commonly overlooked aspect of the HIV care cascade, but ineffective transitions can lead to poor health outcomes for women and their children. In this qualitative study, we conducted interviews with 15 key stakeholders from Ministries of Health along with PEPFAR-supported and other in-country non-governmental organizations actively engaged in national programming for adult HIV care and prevention of mother-to-child-transmission of HIV (PMTCT) services in Côte d'Ivoire, Lesotho and Malawi. We aimed to understand perspectives regarding transitions into and out of PMTCT services for continued ART. Thematic analysis revealed that, although transitions of care are necessary and a potential point of loss from ART care in all three countries, there is a lack of clear guidance on transition approach and no formal way of monitoring transition between services. Several opportunities were identified to monitor and strengthen transitions of care for continued ART along the PMTCT cascade.
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Affiliation(s)
- Tamsin K. Phillips
- Division of Epidemiology and Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Halli Olsen
- Mailman School of Public Health, ICAP-Columbia University, New York, New York, United States of America
| | - Chloe A. Teasdale
- Mailman School of Public Health, ICAP-Columbia University, New York, New York, United States of America
- Department of Epidemiology, Mailman School of Public Health, New York, New York, United States of America
- Department of Epidemiology and Biostatistics, CUNY Graduate School of Public Health & Health Policy, New York, New York, United States of America
| | - Amanda Geller
- Division of Global HIV & TB, US Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, United States of America
| | | | - Nicole Buono
- Division of Global HIV & TB, CDC-Malawi, Lilongwe, Malawi
| | - Dumbani Kayira
- Division of Global HIV & TB, CDC-Malawi, Lilongwe, Malawi
| | - Bernadette Ngeno
- Division of Global HIV & TB, US Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, United States of America
| | - Surbhi Modi
- Division of Global HIV & TB, US Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, United States of America
| | - Elaine J. Abrams
- Mailman School of Public Health, ICAP-Columbia University, New York, New York, United States of America
- Department of Epidemiology, Mailman School of Public Health, New York, New York, United States of America
- College Physicians and Surgeons, Columbia University, New York, New York, United States of America
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Espinosa Dice AL, Bengtson AM, Mwenda KM, Colvin CJ, Lurie MN. Quantifying clinic transfers among people living with HIV in the Western Cape, South Africa: a retrospective spatial analysis. BMJ Open 2021; 11:e055712. [PMID: 34857581 PMCID: PMC8640660 DOI: 10.1136/bmjopen-2021-055712] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 11/03/2021] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES For persons living with HIV (PLWH) in long-term care, clinic transfers are common and influence sustained engagement in HIV care, as they are associated with significant time out-of-care, low CD4 count, and unsuppressed viral load on re-entry. Despite the geospatial nature of clinic transfers, there exist limited data on the geospatial trends of clinic transfers to guide intervention development. In this study, we investigate the geospatial characteristics and trends of clinic transfers among PLWH on antiretroviral therapy (ART) in the Western Cape Province of South Africa. DESIGN Retrospective spatial analysis. SETTING PLWH who initiated ART treatment between 2012 and 2016 in South Africa's Western Cape Province were followed from ART initiation to their last visit prior to 2017. Deidentified electronic medical records from all public clinical, pharmacy, and laboratory visits in the Western Cape were linked across space and time using a unique patient identifier number. PARTICIPANTS 4176 ART initiators in South Africa (68% women). METHODS We defined a clinic transfer as any switch between health facilities that occurred on different days and measured the distance between facilities using geodesic distance. We constructed network flow maps to evaluate geospatial trends in clinic transfers over time, both for individuals' first transfer and overall. RESULTS Two-thirds of ART initiators transferred health facilities at least once during follow-up. Median distance between all clinic transfer origins and destinations among participants was 8.6 km. Participant transfers were heavily clustered around Cape Town. There was a positive association between time on ART and clinic transfer distance, both among participants' first transfers and overall. CONCLUSION This study is among the first to examine geospatial trends in clinic transfers over time among PLWH. Our results make clear that clinic transfers are common and can cluster in urban areas, necessitating better integrated health information systems and HIV care.
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Affiliation(s)
- Ana Lucia Espinosa Dice
- Department of Biostatistics, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Angela M Bengtson
- Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Kevin M Mwenda
- Spatial Structures in the Social Sciences (S4), Population Studies and Training Center (PSTC), Brown University, Providence, Rhode Island, USA
| | - Christopher J Colvin
- Division of Social and Behavioural Sciences, School of Public Health and Family Medicine, University of Cape Town, Observatory, Western Cape, South Africa
- Department of Public Health Sciences, University of Virginia, Charlottesville, Virginia, USA
| | - Mark N Lurie
- Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island, USA
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Etoori D, Rice B, Reniers G, Gomez-Olive FX, Renju J, Kabudula CW, Wringe A. Patterns of engagement in HIV care during pregnancy and breastfeeding: findings from a cohort study in North-Eastern South Africa. BMC Public Health 2021; 21:1710. [PMID: 34544409 PMCID: PMC8454048 DOI: 10.1186/s12889-021-11742-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 08/29/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Eliminating mother-to-child transmission of HIV (MTCT) in sub-Saharan Africa is hindered by limited understanding of HIV-testing and HIV-care engagement among pregnant and breastfeeding women. METHODS We investigated HIV-testing and HIV-care engagement during pregnancy and breastfeeding from 2014 to 2018 in the Agincourt Health and Demographic Surveillance System (HDSS). We linked HIV patient clinic records to HDSS pregnancy data. We modelled time to a first recorded HIV-diagnosis following conception, and time to antiretroviral therapy (ART) initiation following diagnosis using Kaplan-Meier methods. We performed sequence and cluster analyses for all pregnancies linked to HIV-related clinic data to categorise MTCT risk period engagement patterns and identified factors associated with different engagement patterns using logistic regression. We determined factors associated with ART resumption for women who were lost to follow-up (LTFU) using Cox regression. RESULTS Since 2014, 15% of 10,735 pregnancies were recorded as occurring to previously (51%) or newly (49%) HIV-diagnosed women. New diagnoses increased until 2016 and then declined. We identified four MTCT risk period engagement patterns (i) early ART/stable care (51.9%), (ii) early ART/unstable care (34.1%), (iii) late ART initiators (7.6%), and (iv) postnatal seroconversion/early, stable ART (6.4%). Year of delivery, mother's age, marital status, and baseline CD4 were associated with these patterns. A new pregnancy increased the likelihood of treatment resumption following LTFU. CONCLUSION Almost half of all pregnant women did not have optimal ART coverage during the MTCT risk period. Programmes need to focus on improving retention, and leveraging new pregnancies to re-engage HIV-positive women on ART.
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Affiliation(s)
- David Etoori
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Brian Rice
- MeSH Consortium, Department of Public Health Environments and Society, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Georges Reniers
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Francesc Xavier Gomez-Olive
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Jenny Renju
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Chodziwadziwa Whiteson Kabudula
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Alison Wringe
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
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Kwon C, Naser AM, Eilerts H, Reniers G, Argeseanu Cunningham S. Pregnancy Surveillance Methods within Health and Demographic Surveillance Systems. Gates Open Res 2021; 5:144. [PMID: 35382350 PMCID: PMC8960731 DOI: 10.12688/gatesopenres.13332.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/27/2021] [Indexed: 11/25/2022] Open
Abstract
Background: Pregnancy identification and follow-up surveillance can enhance the reporting of pregnancy outcomes, including stillbirths and perinatal and early postnatal mortality. This paper reviews pregnancy surveillance methods used in Health and Demographic Surveillance Systems (HDSSs) in low- and middle-income countries. Methods: We searched articles containing information about pregnancy identification methods used in HDSSs published between January 2002 and October 2019 using PubMed and Google Scholar. A total of 37 articles were included through literature review and 22 additional articles were identified via manual search of references. We reviewed the gray literature, including websites, online reports, data collection instruments, and HDSS protocols from the Child Health and Mortality Prevention Study (CHAMPS) Network and the International Network for the Demographic Evaluation of Populations and Their Health (INDEPTH). In total, we reviewed information from 52 HDSSs described in 67 sources. Results: Substantial variability exists in pregnancy surveillance approaches across the 52 HDSSs, and surveillance methods are not always clearly documented. 42% of HDSSs applied restrictions based on residency duration to identify who should be included in surveillance. Most commonly, eligible individuals resided in the demographic surveillance area (DSA) for at least three months. 44% of the HDSSs restricted eligibility for pregnancy surveillance based on a woman's age, with most only monitoring women 15-49 years. 10% had eligibility criteria based on marital status, while 11% explicitly included unmarried women in pregnancy surveillance. 38% allowed proxy respondents to answer questions about a woman's pregnancy status in her absence. 20% of HDSSs supplemented pregnancy surveillance with investigations by community health workers or key informants and by linking HDSS data with data from antenatal clinics. Conclusions: Methodological guidelines for conducting pregnancy surveillance should be clearly documented and meticulously implemented, as they can have implications for data quality and accurately informing maternal and child health programs.
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Affiliation(s)
- Christie Kwon
- Global Health Institute, Emory University, Atlanta, GA, 30322-4201, USA
| | - Abu Mohd Naser
- Global Health Institute, Emory University, Atlanta, GA, 30322-4201, USA
| | - Hallie Eilerts
- London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - Georges Reniers
- London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
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Bisnauth MA, Davies N, Monareng S, Buthelezi F, Struthers H, McIntyre J, Rees K. Why do patients interrupt and return to antiretroviral therapy? Retention in HIV care from the patient's perspective in Johannesburg, South Africa. PLoS One 2021; 16:e0256540. [PMID: 34473742 PMCID: PMC8412245 DOI: 10.1371/journal.pone.0256540] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 08/09/2021] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Retention in care is required for optimal clinical outcomes in people living with HIV (PLHIV). Although most PLHIV in South Africa know their HIV status, only 70% are on antiretroviral therapy (ART). Improved retention in care is needed to get closer to sustained ART for all. In January 2019, Anova Health Institute conducted a campaign to encourage patients who had interrupted ART to return to care. METHODS Data collection was conducted in one region of Johannesburg. This mixed methods study consisted of two components: 1) healthcare providers entered data into a structured tool for all patients re-initiating ART at nine clinics over a nine-month period, 2) Semi-structured interviews were conducted with a sub-set of patients. Responses to the tool were analysed descriptively, we report frequencies, and percentages. A thematic approach was used to analyse participant experiences in-depth. RESULTS 562 people re-initiated ART, 66% were women, 75% were 25-49 years old. The three most common reasons for disengagement from care were mobility (30%), ART related factors (15%), and time limitations due to work (10%). Reasons for returning included it becoming easier to attend the clinic (34%) and worry about not being on ART (19%). Mobile interview participants often forgot their medical files and expressed that managing their ART was difficult because they often needed a transfer letter to gain access to ART at another facility. On the other hand, clinics that had flexible and extended hours facilitated retention in care. CONCLUSION In both the quantitative data, and the qualitative analysis, changing life circumstances was the most prominent reason for disengagement from care. Health services were not perceived to be responsive to life changes or mobility, leading to disengagement. More client-centred and responsive health services should improve retention on ART.
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Affiliation(s)
| | | | | | | | - Helen Struthers
- Anova Health Institute, Johannesburg, South Africa
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - James McIntyre
- Anova Health Institute, Johannesburg, South Africa
- Division of Infectious Diseases & HIV Medicine, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Kate Rees
- Anova Health Institute, Johannesburg, South Africa
- Department of Community Health, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
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Koech E, Stafford KA, Mutysia I, Katana A, Jumbe M, Awuor P, Lavoie MC, Ngunu C, Riedel DJ, Ojoo S. Factors Associated with Loss to Follow-Up Among Patients Receiving HIV Treatment in Nairobi, Kenya. AIDS Res Hum Retroviruses 2021; 37:642-646. [PMID: 33913735 DOI: 10.1089/aid.2020.0292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
We investigated factors associated with loss to follow-up (LTFU) in 24 urban health facilities in Nairobi, Kenya. We conducted a retrospective analysis of routinely collected data to assess factors associated with LTFU in the period October 1, 2016, to June 30, 2017. LTFU was defined as no antiretroviral therapy (ART) refill for ≥90 days and no documentation of transfer, death, or treatment cessation in the patient chart, and if no lapse of ≥90 days between ART refills, patients were considered retained in care. Multivariable logistic regression modeling was used to compute odds ratios and 95% confidence interval (CI) for LTFU. Our analysis included 633 individuals who were LTFU and 13,098 individuals retained in care. Most participants (69.6%) were women, and median age was 33.0 years (interquartile range, 27.2-38.3 years). Median ART duration was shorter among those LTFU (0.4 years) than retained patients (2.5 years, p < .0001). Being male [adjusted odds ratio (aOR) 1.30; 95% CI: 1.04-1.63, p = .02], transferring into facilities while already receiving ART (aOR 11.58; 95% CI: 8.23-16.29, p < .0001), and having a shorter ART duration (<6 months) were associated with increased odds of LTFU. Patients who transferred into a facility while already receiving ART had the highest adjusted odds of being LTFU compared with those retained in care. In this urban and highly mobile population, transferring into facilities while already receiving ART was strongly associated with LTFU. Focusing programming efforts on patients transferring between urban clinics to identify reasons for transfer and potential barriers to treatment adherence could help improve patient outcomes. Supplementary case management and support may be needed to promote a seamless transition and ensure uninterrupted engagement in HIV care and treatment.
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Affiliation(s)
- Emily Koech
- Center for International Health, Education, and Biosecurity Kenya, University of Maryland, Nairobi, Kenya
| | - Kristen A. Stafford
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Immaculate Mutysia
- Division of Global HIV & TB, U.S. Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Abraham Katana
- Division of Global HIV & TB, U.S. Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Marline Jumbe
- Center for International Health, Education, and Biosecurity Kenya, University of Maryland, Nairobi, Kenya
| | - Patrick Awuor
- Center for International Health, Education, and Biosecurity Kenya, University of Maryland, Nairobi, Kenya
| | - Marie-Claude Lavoie
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | | | - David J. Riedel
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Sylvia Ojoo
- Center for International Health, Education, and Biosecurity Kenya, University of Maryland, Nairobi, Kenya
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Stover J, Glaubius R, Kassanjee R, Dugdale CM. Updates to the Spectrum/AIM model for the UNAIDS 2020 HIV estimates. J Int AIDS Soc 2021; 24 Suppl 5:e25778. [PMID: 34546648 PMCID: PMC8454674 DOI: 10.1002/jia2.25778] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 07/14/2021] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION The Spectrum/AIM model is used by national HIV programs and UNAIDS to prepare annual estimates of key HIV indicators. This article describes key updates to paediatric and adult models for the 2021 round of HIV estimates. METHODS Potential updates to Spectrum arise due to newly available data, new analyses of existing data, and the need for new issues to be addressed. Updates are guided by experts through the UNAIDS Reference Group on Estimates, Modelling and Projections. Changes are tested and assessed for impact before being accepted into the final model. RESULTS Spectrum tracks children living with HIV by CD4% for ages 0-4 and CD4 count for ages 5-14. Data from IeDEA treatment sites have been used to map the transition from CD4% to CD4 count at age 5. Breastfeeding patterns in sub-Saharan Africa have been updated with the latest survey data and estimates of continuation on antiretroviral therapy (ART) with breastfeeding have been revised based on recent studies. Model assumptions about the CD4 counts of people who drop out of ART have been revised to account for CD4 count increases while on treatment. If available, monthly data on numbers on ART can now be used to estimate the effects of COVID-19-related disruptions during 2020. CONCLUSIONS These changes are intended to provide more accurate estimates of HIV burden. The effects of these changes on paediatric indicators are small except in countries with new surveys that might have updated patterns of breastfeeding. Changes to the adult model have little effect on total new infections. AIDS-related deaths will be somewhat lower in countries that have data on ART drop out but might be increased by HIV care disruptions due to COVID-19. The updated model uses newly available data to improve the estimation of paediatric and adult HIV indicators.
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Affiliation(s)
- John Stover
- Center for Modeling, Planning and Policy AnalysisAvenir HealthGlastonburyCTUSA
| | - Robert Glaubius
- Center for Modeling, Planning and Policy AnalysisAvenir HealthGlastonburyCTUSA
| | - Reshma Kassanjee
- Centre for Infectious Disease Epidemiology and Research (CIDER)University of Cape TownCape TownSouth Africa
| | - Caitlin M. Dugdale
- Division of Infectious DiseasesMassachusetts General HospitalBostonMAUSA
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Mody A, Tram KH, Glidden DV, Eshun-Wilson I, Sikombe K, Mehrotra M, Pry JM, Geng EH. Novel Longitudinal Methods for Assessing Retention in Care: a Synthetic Review. Curr HIV/AIDS Rep 2021; 18:299-308. [PMID: 33948789 DOI: 10.1007/s11904-021-00561-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/21/2021] [Indexed: 01/22/2023]
Abstract
PURPOSE OF REVIEW Retention in care is both dynamic and longitudinal in nature, but current approaches to retention often reduce these complex histories into cross-sectional metrics that obscure the nuanced experiences of patients receiving HIV care. In this review, we discuss contemporary approaches to assessing retention in care that captures its dynamic nature and the methodological and data considerations to do so. RECENT FINDINGS Enhancing retention measurements either through patient tracing or "big data" approaches (including probabilistic matching) to link databases from different sources can be used to assess longitudinal retention from the perspective of the patient when they transition in and out of care and access care at different facilities. Novel longitudinal analytic approaches such as multi-state and group-based trajectory analyses are designed specifically for assessing metrics that can change over time such as retention in care. Multi-state analyses capture the transitions individuals make in between different retention states over time and provide a comprehensive depiction of longitudinal population-level outcomes. Group-based trajectory analyses can identify patient subgroups that follow distinctive retention trajectories over time and highlight the heterogeneity of retention patterns across the population. Emerging approaches to longitudinally measure retention in care provide nuanced assessments that reveal unique insights into different care gaps at different time points over an individuals' treatment. These methods help meet the needs of the current scientific agenda for retention and reveal important opportunities for developing more tailored interventions that target the varied care challenges patients may face over the course of lifelong treatment.
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Affiliation(s)
- Aaloke Mody
- Division of Infectious Diseases, Washington University School of Medicine, Campus Box 8051, 4523 Clayton Avenue, St. Louis, Missouri, 63110, USA.
| | - Khai Hoan Tram
- Division of Infectious Diseases, Washington University School of Medicine, Campus Box 8051, 4523 Clayton Avenue, St. Louis, Missouri, 63110, USA
| | - David V Glidden
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | - Ingrid Eshun-Wilson
- Division of Infectious Diseases, Washington University School of Medicine, Campus Box 8051, 4523 Clayton Avenue, St. Louis, Missouri, 63110, USA
| | - Kombatende Sikombe
- Centre for Infectious Diseases Research in Zambia, Lusaka, Zambia
- Department of Public Health Environments and Society, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Megha Mehrotra
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | - Jake M Pry
- Division of Infectious Diseases, Washington University School of Medicine, Campus Box 8051, 4523 Clayton Avenue, St. Louis, Missouri, 63110, USA
- Centre for Infectious Diseases Research in Zambia, Lusaka, Zambia
| | - Elvin H Geng
- Division of Infectious Diseases, Washington University School of Medicine, Campus Box 8051, 4523 Clayton Avenue, St. Louis, Missouri, 63110, USA
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Myburgh H, Reynolds L, Hoddinott G, van Aswegen D, Grobbelaar N, Gunst C, Jennings K, Kruger J, Louis F, Mubekapi-Musadaidzwa C, Viljoen L, Wademan D, Bock P. Implementing 'universal' access to antiretroviral treatment in South Africa: a scoping review on research priorities. Health Policy Plan 2021; 36:923-938. [PMID: 33963393 PMCID: PMC8227479 DOI: 10.1093/heapol/czaa094] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/05/2020] [Indexed: 01/15/2023] Open
Abstract
‘Universal’ access to antiretroviral treatment (ART) has become the global standard for treating people living with HIV and achieving epidemic control; yet, findings from numerous ‘test and treat’ trials and implementation studies in sub-Saharan Africa suggest that bringing ‘universal' access to ART to scale is more complex than anticipated. Using South Africa as a case example, we describe the research priorities and foci in the literature on expanded ART access. To do so, we adapted Arksey and O’Malley’s six-stage scoping review framework to describe the peer-reviewed literature and opinion pieces on expanding access to ART in South Africa between 2000 and 2017. Data collection included systematic searches of two databases and hand-searching of a sub-sample of reference lists. We used an adapted socio-ecological thematic framework to categorize data according to where it located the challenges and opportunities of expanded ART eligibility: individual/client, health worker–client relationship, clinic/community context, health systems infrastructure and/or policy context. We included 194 research articles and 23 opinion pieces, of 1512 identified, addressing expanded ART access in South Africa. The peer-reviewed literature focused on the individual and health systems infrastructure; opinion pieces focused on changing roles of individuals, communities and health services implementers. We contextualized our findings through a consultative process with a group of researchers, HIV clinicians and programme managers to consider critical knowledge gaps. Unlike the published literature, the consultative process offered particular insights into the importance of researching and intervening in the relational aspects of HIV service delivery as South Africa’s HIV programme expands. An overwhelming focus on individual and health systems infrastructure factors in the published literature on expanded ART access in South Africa may skew understanding of HIV programme shortfalls away from the relational aspects of HIV services delivery and delay progress with finding ways to leverage non-medical modalities for achieving HIV epidemic control.
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Affiliation(s)
- Hanlie Myburgh
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Francie van Zijl Drive, Tygerberg, Cape Town, 7505, South Africa.,Amsterdam Institute for Social Science Research (AISSR), University of Amsterdam, Nieuwe Achtergracht 166, WV, Amsterdam, the Netherlands
| | - Lindsey Reynolds
- Department of Sociology and Social Anthropology, Faculty of Arts and Social Sciences, Stellenbosch University, c/o Merriman and Ryneveld Avenue, Stellenbosch, 7600, South Africa
| | - Graeme Hoddinott
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Francie van Zijl Drive, Tygerberg, Cape Town, 7505, South Africa
| | - Dianne van Aswegen
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Francie van Zijl Drive, Tygerberg, Cape Town, 7505, South Africa
| | - Nelis Grobbelaar
- The Anova Health Institute, Willie Van Schoor Avenue, Bellville, Cape Town, 7530, South Africa
| | - Colette Gunst
- Division of Family Medicine and Primary Health Care, Faculty of Medicine and Health Sciences, Stellenbosch University, Francie van Zijl Drive, Tygerberg, Cape Town, 7505, South Africa.,Western Cape Department of Health, Cape Winelands District, 7 Haarlem Street, Worcester, 6850, South Africa
| | - Karen Jennings
- City of Cape Town Health Department, Cape Town Municipality, 12 Hertzog Boulevard, Cape Town, 8001, South Africa
| | - James Kruger
- Western Cape Department of Health, HIV Treatment and PMTCT Programme, 4 Dorp Street, Cape Town, 8000, South Africa
| | - Francoise Louis
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Francie van Zijl Drive, Tygerberg, Cape Town, 7505, South Africa
| | - Constance Mubekapi-Musadaidzwa
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Francie van Zijl Drive, Tygerberg, Cape Town, 7505, South Africa
| | - Lario Viljoen
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Francie van Zijl Drive, Tygerberg, Cape Town, 7505, South Africa
| | - Dillon Wademan
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Francie van Zijl Drive, Tygerberg, Cape Town, 7505, South Africa
| | - Peter Bock
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Francie van Zijl Drive, Tygerberg, Cape Town, 7505, South Africa
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Yohannes NT, Jenkins CA, Clouse K, Cortés CP, Mejía Cordero F, Padgett D, Rouzier V, Friedman RK, McGowan CC, Shepherd BE, Rebeiro PF. Timing of HIV diagnosis relative to pregnancy and postpartum HIV care continuum outcomes among Latin American women, 2000 to 2017. J Int AIDS Soc 2021; 24:e25740. [PMID: 34021715 PMCID: PMC8140191 DOI: 10.1002/jia2.25740] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 04/05/2021] [Accepted: 04/26/2021] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND HIV incidence among women of reproductive age and vertical HIV transmission rates remain high in Latin America. We, therefore, quantified HIV care continuum barriers and outcomes among pregnant women living with HIV (WLWH) in Latin America. METHODS WLWH (aged ≥16 years) enrolling at Caribbean, Central and South America network for HIV epidemiology (CCASAnet) sites from 2000 to 2017 who had HIV diagnosis, pregnancy and delivery dates contributed. Logistic regression produced adjusted odds ratios (aOR) and 95% confidence intervals (CI) for retention in care (≥2 visits ≥3 months apart) and virological suppression (viral load <200 copies/mL) 12 months after pregnancy outcome. Cumulative incidences of loss to follow-up (LTFU) postpartum were estimated using Cox regression. Evidence of HIV status at pregnancy confirmation was the exposure. Covariates included pregnancy outcome (born alive vs. others); AIDS diagnosis prior to delivery; CD4, age, HIV-1 RNA and cART regimen at first delivery and CCASAnet country. RESULTS Among 579 WLWH, median postpartum follow-up was 4.34 years (IQR 1.91, 7.35); 459 (79%) were HIV-diagnosed before pregnancy confirmation, 445 (77%) retained in care and 259 (45%) virologically suppressed at 12 months of postpartum. Cumulative incidence of LTFU was 21% by 12 months and 40% by five years postpartum. Those HIV-diagnosed during pregnancy had lower odds of retention (aOR = 0.58, 95% CI: 0.35 to 0.97) and virological suppression (aOR = 0.50, 95% CI: 0.31 to 0.82) versus those HIV-diagnosed before. CONCLUSION HIV diagnosis during pregnancy was associated with poorer 12-month retention and virological suppression. Young women should be tested and linked to HIV care earlier to narrow these disparities.
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Affiliation(s)
| | - Cathy A Jenkins
- Department of BiostatisticsVanderbilt University Medical CenterNashvilleTNUSA
| | - Kate Clouse
- Division of Infectious DiseasesDepartment of MedicineVanderbilt University Medical CenterNashvilleTNUSA
- Vanderbilt University School of NursingNashvilleTNUSA
| | | | - Fernando Mejía Cordero
- Instituto de Medicina Tropical Alexander von HumboldtUniversidad Peruana Cayetano HerediaLimaPeru
| | - Denis Padgett
- Instituto Hondureño de Seguridad Social & Hospital Escuela UniversitarioTegucigalpaHonduras
| | - Vanessa Rouzier
- Groupe Haitien d'Etudes du Sarcome de Kaposi et des Infections OpportunistesPort‐au‐PrinceHaiti
| | - Ruth K Friedman
- Instituto Nacional de Infectologia Evandro Chagas (INI)Fundação Oswaldo CruzRio de JaneiroBrazil
| | - Catherine C McGowan
- Division of Infectious DiseasesDepartment of MedicineVanderbilt University Medical CenterNashvilleTNUSA
| | - Bryan E Shepherd
- Department of BiostatisticsVanderbilt University Medical CenterNashvilleTNUSA
| | - Peter F Rebeiro
- Department of BiostatisticsVanderbilt University Medical CenterNashvilleTNUSA
- Division of Infectious DiseasesDepartment of MedicineVanderbilt University Medical CenterNashvilleTNUSA
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Outcomes After Being Lost to Follow-up Differ for Pregnant and Postpartum Women When Compared With the General HIV Treatment Population in Rural South Africa. J Acquir Immune Defic Syndr 2021; 85:127-137. [PMID: 32520907 PMCID: PMC7495979 DOI: 10.1097/qai.0000000000002413] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Supplemental Digital Content is Available in the Text. Undetermined attrition prohibits full understanding of the coverage and effectiveness of HIV programs. Outcomes following loss to follow-up (LTFU) among antiretroviral therapy (ART) patients may differ according to their reasons for ART initiation.
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Predictors of retention in the prospective HIV prevention OKAPI cohort in Kinshasa. Sci Rep 2021; 11:5431. [PMID: 33686218 PMCID: PMC7970874 DOI: 10.1038/s41598-021-84839-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 02/15/2021] [Indexed: 11/08/2022] Open
Abstract
Retention is a key element in HIV prevention programs. In Sub-Saharan Africa most data on retention come from HIV clinical trials or people living with HIV attending HIV treatment and control programs. Data from observational cohorts are less frequent. Retention at 6-/12-month follow-up and its predictors were analyzed in OKAPI prospective cohort. From April 2016 to April 2018, 797 participants aged 15-59 years attending HIV Voluntary Counseling and Testing in Kinshasa were interviewed about HIV-related knowledge and behaviors at baseline and at 6- and 12-month follow-ups. Retention rates were 57% and 27% at 6- and 12-month follow up; 22% of participants attended both visits. Retention at 6-month was significantly associated with 12-month retention. Retention was associated with low economic status, being studying, daily/weekly Internet access, previous HIV tests and aiming to share HIV test with partner. Contrarily, perceiving a good health, living far from an antiretroviral center, daily/weekly alcohol consumption and perceiving frequent HIV information were inversely associated with retention. In conclusion, a high attrition was found among people attending HIV testing participating in a prospective cohort in Kinshasa. Considering the low retention rates and the predictors found in this study, more HIV cohort studies in Kinshasa need to be evaluated to identify local factors and strategies that could improve retention if needed.
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Humphrey J, Alera M, Kipchumba B, Pfeiffer EJ, Songok J, Mwangi W, Musick B, Yiannoutsos C, Wachira J, Wools-Kaloustian K. A qualitative study of the barriers and enhancers to retention in care for pregnant and postpartum women living with HIV. PLOS GLOBAL PUBLIC HEALTH 2021; 1:e0000004. [PMID: 36962063 PMCID: PMC10021710 DOI: 10.1371/journal.pgph.0000004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 09/15/2021] [Indexed: 11/18/2022]
Abstract
Retention in care is a major challenge for pregnant and postpartum women living with HIV (PPHIV) in the prevention of mother-to-child HIV transmission (PMTCT) continuum. However, the factors influencing retention from the perspectives of women who have become lost to follow-up (LTFU) are not well described. We explored these factors within an enhanced sub-cohort of the East Africa International Epidemiology Databases to Evaluate AIDS Consortium. From 2018-2019, a purposeful sample of PPHIV ≥18 years of age were recruited from five maternal and child health clinics providing integrated PMTCT services in Kenya. Women retained in care were recruited at the facility; women who had become LTFU (last visit >90 days) were recruited through community tracking. Interview transcripts were analyzed thematically using a social-ecological framework. Forty-one PPHIV were interviewed. The median age was 27 years, 71% were pregnant, and 39% had become LTFU. In the individual domain, prior PMTCT experience and desires to safeguard infants' health enhanced retention but were offset by perceived lack of value in PMTCT services following infants' immunizations. In the peer/family domain, male-partner financial and motivational support enhanced retention. In the community/society domain, some women perceived social pressure to attend clinic while others perceived pressure to utilize traditional birth attendants. In the healthcare environment, long queues and negative provider attitudes were prominent barriers. HIV-related stigma and fear of disclosure crossed multiple domains, particularly for LTFU women, and were driven by perceptions of HIV as a fatal disease and fear of partner abandonment and abuse. Both retained and LTFU women perceived that integrated HIV services increased the risk of disclosure. Retention was influenced by multiple factors for PPHIV. Stigma and fear of disclosure were prominent barriers for LTFU women. Multicomponent interventions and refining the structure and efficiency of PMTCT services may enhance retention for PPHIV.
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Affiliation(s)
- John Humphrey
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, United States of America
| | - Marsha Alera
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | - Bett Kipchumba
- Department of Reproductive Health, Moi Teaching and Referral Hospital, Eldoret, Kenya
| | - Elizabeth J Pfeiffer
- Department of Anthropology, Rhode Island College, Providence, RI, United States of America
| | - Julia Songok
- Department of Child Health and Paediatrics, College of Health Sciences, Moi University, Eldoret, Kenya
| | - Winfred Mwangi
- Department of Reproductive Health, Moi Teaching and Referral Hospital, Eldoret, Kenya
| | - Beverly Musick
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN, United States of America
| | - Constantin Yiannoutsos
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN, United States of America
| | - Juddy Wachira
- Department of Behavioral Sciences, College of Health Sciences, Moi University, Eldoret, Kenya
| | - Kara Wools-Kaloustian
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, United States of America
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White M, Feucht UD, Duffley E, Molokoane F, Durandt C, Cassol E, Rossouw T, Connor KL. Does in utero HIV exposure and the early nutritional environment influence infant development and immune outcomes? Findings from a pilot study in Pretoria, South Africa. Pilot Feasibility Stud 2020; 6:192. [PMID: 33308322 PMCID: PMC7730756 DOI: 10.1186/s40814-020-00725-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Accepted: 11/11/2020] [Indexed: 03/08/2023] Open
Abstract
Background As mother-to-child transmission of HIV decreases, and the population of infants who are born HIV-exposed, but uninfected (HEU) continues to rise, there is a growing need to understand the development and health outcomes of infants who are HEU to ensure that they have the healthiest start to life. Methods In a prospective cohort pilot study at Kalafong Hospital, Pretoria, South Africa, we aimed to determine if we could recruit new mothers living with HIV on antiretrovirals (ART; n = 20) and not on ART (n = 20) and new mothers without HIV (n = 20) through our clinics to study the effects of HEU on growth and immune- and neurodevelopment in infants in early life, and test the hypothesis that infants who were HEU would have poorer health outcomes compared to infants who were HIV-unexposed, uninfected (HUU). We also undertook exploratory analyses to investigate relationships between the early nutritional environment, food insecurity and infant development. Infant growth, neurodevelopment (Guide for Monitoring Child Development [GMCD]) and levels of monocyte subsets (CD14, CD16 and CCR2 expression [flow cytometry]) were measured in infants at birth and 12 weeks (range 8–16 weeks). Results We recruited 33 women living with HIV on ART and 22 women living without HIV within 4 days of delivery from June to December 2016. Twenty-one women living with HIV and 10 without HIV returned for a follow-up appointment at 12 weeks postpartum. The high mobility of this population presented major challenges to participant retention. Preliminary analyses revealed lower head circumference and elevated CCR2+ (% and median fluorescence intensity) on monocytes at birth among infants who were HEU compared to HUU. Maternal reports of food insecurity were associated with lower maternal nutrient intakes at 12 weeks postpartum and increased risk of stunting at birth for infants who were HEU, but not infants who were HUU. Conclusions Our small feasibility pilot study suggests that HEU may adversely affect infant development, and further, infants who are HEU may be even more vulnerable to the programming effects of suboptimal nutrition in utero and postnatally. This pilot and preliminary analyses have been used to inform our research questions and protocol in our ongoing, full-scale study.
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Affiliation(s)
- Marina White
- Department of Health Sciences, Carleton University, Ottawa, ON, K1S 5B6, Canada
| | - Ute D Feucht
- Paediatrics, University of Pretoria, Pretoria, GP 0002, South Africa.,Research Centre for Maternal, Fetal, Newborn & Child Health Care Strategies, University of Pretoria, Pretoria, GP 0002, South Africa.,Maternal and Infant Health Care Strategies Unit, South African Medical Council, Pretoria, South Africa
| | - Eleanor Duffley
- Department of Health Sciences, Carleton University, Ottawa, ON, K1S 5B6, Canada
| | - Felicia Molokoane
- Research Centre for Maternal, Fetal, Newborn & Child Health Care Strategies, University of Pretoria, Pretoria, GP 0002, South Africa.,Maternal and Infant Health Care Strategies Unit, South African Medical Council, Pretoria, South Africa.,Obstetrics and Gynaecology, University of Pretoria, Pretoria, GP, 0002, South Africa
| | - Chrisna Durandt
- South African Medical Research Council Extramural Unit for Stem Cell Research and Therapy, University of Pretoria, Pretoria, GP 0002, South Africa.,Institute for Cellular and Molecular Medicine, Department of Immunology, University of Pretoria, Pretoria, GP 0002, South Africa
| | - Edana Cassol
- Department of Health Sciences, Carleton University, Ottawa, ON, K1S 5B6, Canada
| | - Theresa Rossouw
- Institute for Cellular and Molecular Medicine, Department of Immunology, University of Pretoria, Pretoria, GP 0002, South Africa
| | - Kristin L Connor
- Department of Health Sciences, Carleton University, Ottawa, ON, K1S 5B6, Canada.
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Clouse K, Malope-Kgokong B, Bor J, Nattey C, Mudau M, Maskew M. The South African National HIV Pregnancy Cohort: evaluating continuity of care among women living with HIV. BMC Public Health 2020; 20:1662. [PMID: 33153468 PMCID: PMC7643452 DOI: 10.1186/s12889-020-09679-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 10/12/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND South Africa is home to more people living with HIV than any other country, including nearly one in three pregnant women attending antenatal care. Access to antiretroviral therapy (ART) has increased substantially since the start of the national ART program in 2004, with > 95% ART coverage during pregnancy and delivery, and vertical transmission of HIV greatly reduced. However, women who initiate ART during pregnancy are at heightened risk of dropping out of care, particularly after delivery, leading to the potential for viral transmission, morbidity and mortality. It is difficult to evaluate the success of policies of expanded access to ART care, and assess continuity of care, due to the lack of a national longitudinal HIV care database. Also, patient movement between unlinked facilities. For the first time on a national level, we propose to utilize routinely-collected laboratory data to develop and validate a cohort of pregnant women living with HIV in South Africa in a way that is uniquely robust to facility transfer. METHODS Using laboratory test data matched to facility type, we will identify entry to antenatal care to build the cohort, then describe key treatment milestones, including 1) engagement in antenatal care, 2) initiation of ART, 3) HIV viremia, and 4) continuity of HIV care in the postpartum period. Second, we will measure the effect of system-wide factors impacting continuity of care among pregnant women. We will assess policies of expanded treatment access on continuity of care using regression-discontinuity analyses. We then will assess mobility and its effect on continuity of care during and after pregnancy. Third, we will identify individual-level risk factors for loss from HIV care in order to develop targeted interventions to improve engagement in HIV care. DISCUSSION This work will create the world's largest national cohort of pregnant women living with HIV. This novel cohort will be a powerful tool available to policymakers, clinicians and researchers for improving our understanding of engagement in care among pregnant women in South Africa and assessing the performance of the South African national ART program in caring for pregnant women living with HIV. TRIAL REGISTRATION N/A (not a clinical trial).
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Affiliation(s)
- Kate Clouse
- Vanderbilt University School of Nursing, Nashville, TN USA
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, TN USA
- Health Economics and Epidemiology Research Office (HE2RO), Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Babatyi Malope-Kgokong
- Academic Affairs and Research, National Health Laboratory Service, Johannesburg, South Africa
| | - Jacob Bor
- Health Economics and Epidemiology Research Office (HE2RO), Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health, Boston University School of Public Health, Boston, MA USA
- Department of Epidemiology, Boston University School of Public Health, Boston, MA USA
| | - Cornelius Nattey
- Health Economics and Epidemiology Research Office (HE2RO), Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Maanda Mudau
- Academic Affairs and Research, National Health Laboratory Service, Johannesburg, South Africa
| | - Mhairi Maskew
- Health Economics and Epidemiology Research Office (HE2RO), Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Sikombe K, Mody A, Kadota J, Pry J“J, Simbeza S, Eshun-Wilson I, Situmbeko SR, Bukankala C, Beres L, Mukamba N, Wa Mwanza M, Bolton- Moore C, Holmes CB, Geng EH, Sikazwe I. Understanding patient transfers across multiple clinics in Zambia among HIV infected adults. PLoS One 2020; 15:e0241477. [PMID: 33147250 PMCID: PMC7641414 DOI: 10.1371/journal.pone.0241477] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 10/15/2020] [Indexed: 12/30/2022] Open
Abstract
Many patients in HIV care in Africa considered lost to follow up (LTFU) at one facility are reportedly accessing care in another. The success of these unofficial transfers as measured by time to re-entry at the new-facility, prevalence of treatment interruptions, speed of ART-initiation, and overall continuity of care is not well characterized but may reveal opportunities for improvement. We traced a random sample of LTFU HIV-infected patients in Zambia. Among those found alive and reported in care at a new-facility, we reviewed records at the receiving facility to verify transfer; and when verified, documented the transfer experience. We used Kaplan-Meier methods to examine incidence of ART-initiation after transfer to new clinic. We assessed demographic and clinical characteristics, official and cross-provincial transfer for associations with HIV treatment re-engagement using Poisson regression models and associations between official-transfer and same-day ART initiation at the new-facility. Among 350 LTFU-patients, 178 (51%) were successfully verified through chart review at the new-facility. 132 (74.2%) were female, 72 (40.4%) aged 25-35, and 51% were ever recorded as previously being on ART. 110 patients (61.8%) were registered under new ART-IDs and 97 (54.5%) received a new HIV test. 54% of those previously on ART-initiated on the same-day. Using the same ART-ID was associated with same-day initiation compared to those receiving a new ART-ID (p = 0.07). 80% (n = 91) of those ever on ART had evidence of medication initiation at new clinic. Among these, initiation reached 66% (95% CI: 56-75) by 30 days, 77.5% (95% CI: 68-86) by 90 days after new-facility presentation. Many patients use new identifiers at new facilities, indicative of inefficiencies. Re-entry into new facilities among the unofficial-transfer population is often delayed and timely treatment initiation is inconsistent, suggesting interruptions in treatment. Health systems innovations to ensure smooth and safe transfers are needed to maintain quality HIV care.
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Affiliation(s)
- Kombatende Sikombe
- Research Department, Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- Department of Public Health, Environments and Society, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Aaloke Mody
- Division of Infectious Diseases, Washington University School of Medicine, Washington University in St. Louis, St. Louis, Missouri, United States of America
| | - Jillian Kadota
- Division of Pulmonary and Critical Care Medicine and Center for Tuberculosis, University of California San Francisco, San Francisco, California, United States of America
| | - Jesse “Jake” Pry
- Research Department, Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- Division of Infectious Diseases, Washington University School of Medicine, Washington University in St. Louis, St. Louis, Missouri, United States of America
| | - Sandra Simbeza
- Research Department, Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Ingrid Eshun-Wilson
- Division of Infectious Diseases, Washington University School of Medicine, Washington University in St. Louis, St. Louis, Missouri, United States of America
| | | | - Chama Bukankala
- Research Department, Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Laura Beres
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Njekwa Mukamba
- Research Department, Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Mwanza Wa Mwanza
- Research Department, Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Carolyn Bolton- Moore
- Research Department, Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- Division of Infectious Diseases, University of Alabama, Birmingham, Alabama, United States of America
| | - Charles B. Holmes
- Research Department, Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- Center for Global Health and Quality, Georgetown University, Washington, District of Columbia, United States of America
| | - Elvin H. Geng
- Division of Infectious Diseases, Washington University School of Medicine, Washington University in St. Louis, St. Louis, Missouri, United States of America
| | - Izukanji Sikazwe
- Research Department, Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
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Hannaford A, Moll AP, Madondo T, Khoza B, Shenoi SV. Mobility and structural barriers in rural South Africa contribute to loss to follow up from HIV care. AIDS Care 2020; 33:1436-1444. [PMID: 32856470 DOI: 10.1080/09540121.2020.1808567] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Retention in HIV care is crucial to sustaining viral load suppression, and reducing HIV transmission, yet loss to follow-up (LTFU) in South Africa remains substantial. We conducted a mixed methods evaluation in rural South Africa to characterize ART disengagement in neglected rural settings. Using convenience sampling, surveys were completed by 102 PLWH who disengaged from ART (minimum 90 days) and subsequently resumed care. A subset (n = 60) completed individual in-depth interviews. Median duration of ART discontinuation was 9 months (IQR 4-22). Participants had HIV knowledge gaps regarding HIV transmission and increased risk of tuberculosis. The major contributors to LTFU were mobility and structural barriers. PLWH traveled for an urgent family need or employment, and were not able to collect ART while away. Structural barriers included inability to access care, due to lack of financial resources to reach distant clinics. Other factors included dissatisfaction with care, pill fatigue, lack of social support, and stigma. Illness was the major precipitant of returning to care. Mobility and structural barriers impede longitudinal HIV care in rural South Africa, threatening the gains made from expanded ART access. To achieve 90-90-90, future interventions, including emphasis on patient centered care, must address barriers relevant to rural settings.
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Affiliation(s)
- Alisse Hannaford
- Department of Internal Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Anthony P Moll
- Church of Scotland Hospital, Tugela Ferry, South Africa.,Philanjalo NGO, Tugela Ferry, South Africa
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Zerbe A, Brittain K, Phillips TK, Iyun VO, Allerton J, Nofemela A, Kalombo CD, Myer L, Abrams EJ. Community-based adherence clubs for postpartum women on antiretroviral therapy (ART) in Cape Town, South Africa: a pilot study. BMC Health Serv Res 2020; 20:621. [PMID: 32641032 PMCID: PMC7341610 DOI: 10.1186/s12913-020-05470-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 06/25/2020] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND With an increasing number of countries implementing Option B+ guidelines of lifelong antiretroviral therapy (ART) for all pregnant and breastfeeding women, there is urgent need to identify effective approaches for retaining this growing and highly vulnerable population in ART care. METHODS Newly postpartum, breastfeeding women who initiated ART in pregnancy and met eligibility criteria were enrolled, and offered the choice of two options for postpartum ART care: (i) referral to existing network of community-based adherence clubs or (ii) referral to local primary health care clinic (PHC). Women were followed at study measurement visits conducted separately from either service. Primary outcome was a composite endpoint of retention in ART services and viral suppression [VS < 50 copies/mL based on viral load (VL) testing at measurement visits] at 12 months postpartum. Outcomes were compared across postpartum services using chi-square, Fisher's exact tests and Poisson regression models. The primary outcome was compared across services where women were receiving care at 12 months postpartum in exploratory analyses. RESULTS Between February and September 2015, 129 women (median age: 28.9 years; median time postpartum: 10 days) were enrolled with 65% opting to receive postpartum HIV care through an adherence club. Among 110 women retained at study measurement visits, 91 (83%) achieved the composite endpoint, with no difference between those who originally chose clubs versus those who chose PHC services. Movement from an adherence club to PHC services was common: 31% of women who originally chose clubs and were engaged in care at 12 months postpartum were attending a PHC service. Further, levels of VS differed significantly by where women were accessing ART care at 12 months postpartum, regardless of initial choice: 98% of women receiving care in an adherence club and 76% receiving care at PHC had VS < 50 copies/mL at 12 months postpartum (p = 0.001). CONCLUSION This study found comparable outcomes related to retention and VS at 12 months postpartum between women choosing adherence clubs and those choosing PHC. However, movement between postpartum services among those who originally chose adherence clubs was common, with poorer VS outcomes among women leaving clubs and returning to PHC services. TRIAL REGISTRATION ClinicalTrials.gov NCT02417675 , April 16, 2015 (retrospectively registered).
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Affiliation(s)
- Allison Zerbe
- ICAP, Mailman School of Public Health, Columbia University, 722 W. 168th street, 13th floor, New York, 10032 USA
| | - Kirsty Brittain
- Centre for Infectious Disease Epidemiology & Research, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Tamsin K. Phillips
- Centre for Infectious Disease Epidemiology & Research, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Victoria O. Iyun
- Centre for Infectious Disease Epidemiology & Research, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Joanna Allerton
- Centre for Infectious Disease Epidemiology & Research, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Andile Nofemela
- Centre for Infectious Disease Epidemiology & Research, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Cathy D. Kalombo
- Provincial Government of the Western Cape, Cape Town, South Africa
| | - Landon Myer
- Centre for Infectious Disease Epidemiology & Research, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Elaine J. Abrams
- ICAP, Mailman School of Public Health, Columbia University, 722 W. 168th street, 13th floor, New York, 10032 USA
- Vagelos College of Physicians & Surgeons, Columbia University, New York, USA
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Kwena Z, Nakamanya S, Nanyonjo G, Okello E, Fast P, Ssetaala A, Oketch B, Price M, Kapiga S, Bukusi E, Seeley J. Understanding mobility and sexual risk behaviour among women in fishing communities of Lake Victoria in East Africa: a qualitative study. BMC Public Health 2020; 20:944. [PMID: 32539818 PMCID: PMC7296721 DOI: 10.1186/s12889-020-09085-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 06/10/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND HIV-prevalence and incidence is high in many fishing communities around Lake Victoria in East Africa. In these settings, mobility among women is high and may contribute to increased risk of HIV infection and poor access to effective prevention and treatment services. Understanding the nature and patterns of this mobility is important for the design of interventions. We conducted an exploratory study to understand the nature and patterns of women's mobility to inform the design of HIV intervention trials in fishing communities of Lake Victoria. METHODS This was a cross-sectional formative qualitative study conducted in six purposively selected fishing communities in Kenya, Tanzania and Uganda. Potential participants were screened for eligibility on age (18+ years) and having stayed in the fishing community for more than 6 months. We collected data using introductory and focus group discussions, and in-depth interviews with key informants. Data focused on: history and patterns of mobility, migration in and out of fishing communities and the relationship between mobility and HIV infection. Since the interviews and discussions were not audio-recorded, detailed notes were taken and written up into full scripts for analysis. We conducted a thematic analysis using constant comparison analysis. RESULTS Participants reported that women in fishing communities were highly mobile for work-related activities. Overall, we categorized mobility as travels over long and short distances or periods depending on the kind of livelihood activity women were involved in. Participants reported that women often travelled to new places, away from familiar contacts and far from healthcare access. Some women were reported to engage in high risk sexual behaviour and disengaging from HIV care. However, participants reported that women often returned to the fishing communities they considered home, or followed a seasonal pattern of work, which would facilitate contact with service providers. CONCLUSION Women exhibited circular and seasonal mobility patterns over varying distances and duration away from their home communities. These mobility patterns may limit women's access to trial/health services and put them at risk of HIV-infection. Interventions should be tailored to take into account mobility patterns of seasonal work observed in this study.
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Affiliation(s)
- Zachary Kwena
- Research Care and Training Program (RCTP), Kenya Medical Research Institute, Kisumu, Kenya.
| | - Sarah Nakamanya
- Medical Research Council/Uganda Virus Research Institute MRC/UVRI and London School of Hygiene and Tropical Medicine (LSHTM) Uganda Research Unit, Entebbe, Uganda
| | - Gertrude Nanyonjo
- Uganda Virus Research Institute-International AIDS Vaccine Initiative (UVRI-IAVI) Project, Uganda Virus Research Institute, Entebbe, Uganda
| | - Elialilia Okello
- Mwanza Intervention Trials Unit (MITU), National Institute for Medical Research, Mwanza, Tanzania
| | - Pat Fast
- International AIDS Vaccine Initiative (IAVI), New York, USA
| | - Ali Ssetaala
- Uganda Virus Research Institute-International AIDS Vaccine Initiative (UVRI-IAVI) Project, Uganda Virus Research Institute, Entebbe, Uganda
| | - Bertha Oketch
- Research Care and Training Program (RCTP), Kenya Medical Research Institute, Kisumu, Kenya
| | - Matt Price
- International AIDS Vaccine Initiative (IAVI), New York, USA
| | - Saidi Kapiga
- Mwanza Intervention Trials Unit (MITU), National Institute for Medical Research, Mwanza, Tanzania
- London School of Hygiene and Tropical Medicine, London, UK
| | - Elizabeth Bukusi
- Research Care and Training Program (RCTP), Kenya Medical Research Institute, Kisumu, Kenya
| | - Janet Seeley
- Medical Research Council/Uganda Virus Research Institute MRC/UVRI and London School of Hygiene and Tropical Medicine (LSHTM) Uganda Research Unit, Entebbe, Uganda
- London School of Hygiene and Tropical Medicine, London, UK
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Rucinski KB, Schwartz SR, Powers KA, Pence BW, Chi BH, Black V, Rees H, Pettifor AE. Fertility Intentions and Clinical Care Attendance Among Women Living with HIV in South Africa. AIDS Behav 2020; 24:1585-1591. [PMID: 31228024 PMCID: PMC6925340 DOI: 10.1007/s10461-019-02564-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Poor HIV care retention impedes optimal treatment outcomes in persons living with HIV. Women trying to become pregnant may be motivated by periconception horizontal and vertical transmission concerns and thus more likely to attend HIV care visits than women not trying to conceive. We estimated the effect of fertility intentions on HIV care attendance over 12 months among non-pregnant, HIV-positive women aged 18-35 years who were on or initiating antiretroviral therapy in Johannesburg, South Africa. The percentage of women attending an HIV care visit decreased from 93.4% in the first quarter to 82.8% in the fourth quarter. Fertility intentions were not strongly associated with care attendance in this cohort of reproductive-aged women; however, attendance declined over time irrespective of childbearing plans. These findings suggest a need for reinforced efforts to support care engagement and risk reduction, including safer conception practices for women wishing to conceive.
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Affiliation(s)
- Katherine B Rucinski
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, E7133A, Baltimore, MD, 21205, USA.
- Wits RHI, University of the Witwatersrand, Johannesburg, South Africa.
| | - Sheree R Schwartz
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, E7133A, Baltimore, MD, 21205, USA
- Wits RHI, University of the Witwatersrand, Johannesburg, South Africa
| | - Kimberly A Powers
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Brian W Pence
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Benjamin H Chi
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Vivian Black
- Wits RHI, University of the Witwatersrand, Johannesburg, South Africa
- Clinical Microbiology and Infectious Diseases, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Helen Rees
- Wits RHI, University of the Witwatersrand, Johannesburg, South Africa
| | - Audrey E Pettifor
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC, USA
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Bassett IV, Huang M, Cloete C, Candy S, Giddy J, Frank SC, Freedberg KA, Losina E, Walensky RP, Parker RA. Using national laboratory data to assess cumulative frequency of linkage after transfer to community-based HIV clinics in South Africa. J Int AIDS Soc 2020; 22:e25326. [PMID: 31243898 PMCID: PMC6595194 DOI: 10.1002/jia2.25326] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Accepted: 05/22/2019] [Indexed: 12/29/2022] Open
Abstract
Introduction Changes to the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) funding have led to closures of non‐governmental HIV clinics with patient transfers to government‐funded clinics. We sought to determine the success of transfers in South Africa using a national data source. Methods All adults (≥18 years) on antiretroviral therapy (ART) who visited a single PEPFAR‐funded hospital‐based HIV clinic in Durban, South Africa from March to June 2012 were transferred to community‐based clinics. Previously, we matched patient records from the hospital‐based HIV clinic with National Health Laboratory Services (NHLS) Corporate Data Warehouse (CDW) data to estimate the proportion of patients with a CD4 count or viral load (VL) in the CDW during the year before transfer. As a proxy for retention in care, in this study we evaluated whether patients had a CD4 count or VL at another facility within approximately three years of transfer. Patients referred to a private doctor at transfer were excluded from the analysis. We assessed predictors (age, sex, CD4 count, VL status, ART duration and location of future care) of not having post‐transfer laboratory data using Cox proportional hazards models. Results Of the 3893 patients referred to a government facility at transfer, 41% were male and median age was 39 years (IQR 34 to 46). There was a post‐transfer CD4 count or VL from another facility for 23% of these individuals within six months, 44% within one year, 57% within two years and 61% within approximately three years. Male sex (aHR 1.20, 95% CI 1.10 to 1.31) and shorter duration on ART (<3 months, aHR 3.80, 95% CI 2.77 to 5.21; three months to one year, aHR 1.32, 95% CI 1.15 to 1.51, each compared with >1 year) were associated with not having a post‐transfer record. Conclusions Using data from the NHLS CDW, 61% of patients had evidence of a post‐transfer laboratory record at another facility within approximately three years after closure of a large South African HIV clinic. Males and those with shorter time on ART prior to transfer were at highest risk for lacking follow‐up laboratory data. As patients transfer care, national data sources can be used to evaluate long‐term patient care trajectories.
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Affiliation(s)
- Ingrid V Bassett
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA.,Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA.,Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.,Harvard University Center for AIDS Research (CFAR), Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Mingshu Huang
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA.,Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.,Harvard University Center for AIDS Research (CFAR), Boston, MA, USA.,Biostatistics Center, Massachusetts General Hospital, Boston, MA, USA
| | | | - Sue Candy
- Department of Academic Affairs, Research and Quality Assurance, Corporate Data Warehouse, National Health Laboratory Services, Johannesburg, South Africa
| | | | - Simone C Frank
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA.,Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Kenneth A Freedberg
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA.,Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA.,Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.,Harvard University Center for AIDS Research (CFAR), Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Departments of Epidemiology and Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Elena Losina
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.,Harvard University Center for AIDS Research (CFAR), Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Departments of Biostatistics and Epidemiology, Boston University School of Public Health, Boston, MA, USA.,Division of Rheumatology, Department of Medicine, and Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Rochelle P Walensky
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA.,Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA.,Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.,Harvard University Center for AIDS Research (CFAR), Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Robert A Parker
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.,Harvard University Center for AIDS Research (CFAR), Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Biostatistics Center, Massachusetts General Hospital, Boston, MA, USA
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Etoori D, Wringe A, Kabudula CW, Renju J, Rice B, Gomez-Olive FX, Reniers G. Misreporting of Patient Outcomes in the South African National HIV Treatment Database: Consequences for Programme Planning, Monitoring, and Evaluation. Front Public Health 2020; 8:100. [PMID: 32318534 PMCID: PMC7154050 DOI: 10.3389/fpubh.2020.00100] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 03/12/2020] [Indexed: 01/20/2023] Open
Abstract
Background: Monitoring progress toward global treatment targets using HIV programme data in sub-Saharan Africa has proved challenging. Constraints in routine data collection and reporting can lead to biased estimates of treatment outcomes. In 2010, South Africa introduced an electronic patient monitoring system for HIV patient visits, TIER.Net. We compare treatment status and outcomes recorded in TIER.Net to outcomes ascertained through detailed record review and tracing in order to assess discrepancies and biases in retention and mortality rates. Methods: The Agincourt Health and Demographic Surveillance System (HDSS) in north-eastern South Africa is served by eight public primary healthcare facilities. Since 2014, HIV patient visits are logged electronically at these clinics, with patient records individually linked to their HDSS record. These data were used to generate a list of patients >90 days late for their last scheduled clinic visit and deemed lost to follow-up (LTFU). Patient outcomes were ascertained through a review of the TIER.Net database, physical patient files, registers kept by two non-government organizations that assist with patient tracing, cross-referencing with the HDSS records and supplementary physical tracing. Descriptive statistics were used to compare patient outcomes reported in TIER.Net to their outcome ascertained in the study. Results: Of 1,074 patients that were eligible for this analysis, TIER.Net classified 533 (49.6%) as LTFU, 80 (7.4%) as deceased, and 186 (17.3%) as transferred out. TIER.Net misclassified 36% of patient outcomes, overestimating LTFU and underestimating mortality and transfers out. TIER.Net missed 40% of deaths and 43% of transfers out. Patients categorized as LTFU in TIER.Net were more likely to be misclassified than patients classified as deceased or transferred out. Discussion: Misclassification of patient outcomes in TIER.Net has consequences for programme forecasting, monitoring and evaluation. Undocumented transfers accounted for the majority of misclassification, suggesting that the transfer process between clinics should be improved for more accurate reporting of patient outcomes. Processes that lead to correct classification of patient status including patient tracing should be strengthened. Clinics could cross-check all available data sources before classifying patients as LTFU. Programme evaluators and modelers could consider using correction factors to improve estimates of outcomes from TIER.Net.
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Affiliation(s)
- David Etoori
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Alison Wringe
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Chodziwadziwa Whiteson Kabudula
- MRC/WITS Rural Public Health Transitions Research Unit (Agincourt), Faculty of Health Sciences, School of Public Health, University of Witwatersrand, Johannesburg, South Africa
| | - Jenny Renju
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Brian Rice
- MeSH Consortium, Department of Public Health Environments and Society, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - F. Xavier Gomez-Olive
- MRC/WITS Rural Public Health Transitions Research Unit (Agincourt), Faculty of Health Sciences, School of Public Health, University of Witwatersrand, Johannesburg, South Africa
| | - Georges Reniers
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
- MRC/WITS Rural Public Health Transitions Research Unit (Agincourt), Faculty of Health Sciences, School of Public Health, University of Witwatersrand, Johannesburg, South Africa
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Phillips TK, Orrell C, Brittain K, Zerbe A, Abrams EJ, Myer L. Measuring retention in HIV care: the impact of data sources and definitions using routine data. AIDS 2020; 34:749-759. [PMID: 32004202 PMCID: PMC7109335 DOI: 10.1097/qad.0000000000002478] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Measuring retention is critical for antiretroviral therapy (ART) management and program monitoring; however, many definitions and data sources, usually from single health facilities, are used. We used routine electronic data, linked across facilities, to examine the impact of definitions and data sources on retention estimates among women in Cape Town, South Africa. DESIGN Retrospective cohort study. METHODS We compiled routine electronic laboratory, pharmacy and clinic visit data for 617 women who started ART during pregnancy (2013-2014) and estimated 24-month retention using different definitions and data sources. We used logistic regression to assess consistency of associations between risk factors and retention, and receiver operating characteristics analyses to describe how different retention estimates predict viremia at 12 months on ART. RESULTS Using all available data sources, retention ranged from 41% (no gap >180 days) to 72% (100% 12-month visit constancy). Laboratory data (expected infrequently) underestimated retention compared with clinic visit data that identified more than 80% of women considered retained in all definitions. In all estimates, associations with known risk factors for nonretention remained consistent and retention declined over time: 77, 65 and 58% retained using all data sources in months 6-12, 12-18 and 18-24, respectively (P < 0.001). The 180-day gap definition was most strongly associated with viremia (odds ratio 24.3 95% confidence interval 12.0-48.9, all data sources). CONCLUSION Researchers must carefully consider the most appropriate retention definition and data source depending on available data. Presenting more than one approach may be warranted to obtain estimates that are context-appropriate and comparable across settings.
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Affiliation(s)
- Tamsin K Phillips
- Division of Epidemiology & Biostatistics
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town
| | - Catherine Orrell
- Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Kirsty Brittain
- Division of Epidemiology & Biostatistics
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town
| | - Allison Zerbe
- ICAP at Columbia University, Mailman School of Public Health
| | - Elaine J Abrams
- ICAP at Columbia University, Mailman School of Public Health
- Vagelos College of Physicians & Surgeons, Columbia University, New York, New York, USA
| | - Landon Myer
- Division of Epidemiology & Biostatistics
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town
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50
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Clouse K, Phillips TK, Camlin C, Noholoza S, Mogoba P, Naidoo J, Langford R, Weiss M, Seebregts CJ, Myer L. CareConekta: study protocol for a randomized controlled trial of a mobile health intervention to improve engagement in postpartum HIV care in South Africa. Trials 2020; 21:258. [PMID: 32164771 PMCID: PMC7068940 DOI: 10.1186/s13063-020-4190-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 02/19/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND South Africa is home to the world's largest antiretroviral therapy program but sustaining engagement along the HIV care continuum has proven challenging in the country and throughout the wider region. Population mobility is common in South Africa, but there are important research gaps in describing this mobility and its impact on engagement in HIV care. Postpartum women and their infants in South Africa are known to be at high risk of dropping out of HIV care after delivery and are frequently mobile. METHODS In 2017, we developed a beta version of a smartphone application (app) - CareConekta - that detects a user's smartphone location to allow for prospective characterization of mobility. Now we will adapt and test CareConekta to conduct essential formative work on mobility and evaluate an intervention - the CareConekta app plus text notifications and phone calls and/or WhatsApp messages - to facilitate engagement in HIV care during times of mobility. During the 3-year project period, our first objective is to evaluate the feasibility, acceptability, and initial efficacy of using CareConekta as an intervention to improve engagement in HIV care. Our second objective is to characterize mobility among South African women during the peripartum period and its impact on engagement in HIV care. We will enroll 200 eligible pregnant women living with HIV and receiving care at the Gugulethu Midwife Obstetric Unit in Cape Town, South Africa. DISCUSSION This work will provide critical information about mobility during the peripartum period and the impact on engagement in HIV care. Simultaneously, we will pilot test an intervention to improve engagement with rigorously assessed outcomes. If successful, CareConekta offers tremendous potential as a research and service tool that can be adapted and evaluated in multiple geographic regions, study contexts, and patient populations. TRIAL REGISTRATION ClinicalTrials.gov: NCT03836625. Registered on 8 February 2019.
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Affiliation(s)
- Kate Clouse
- Vanderbilt University School of Nursing, Nashville, TN USA
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, TN USA
| | - Tamsin K. Phillips
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
- Center for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Carol Camlin
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, CA USA
- Center for AIDS Prevention Studies, Division of Prevention Science, Department of Medicine, University of California, San Francisco, CA USA
| | - Sandisiwe Noholoza
- Center for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Phepo Mogoba
- Center for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | | | | | | | | | - Landon Myer
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
- Center for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
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