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Ogola B, Matume ND, Tebit DM, Mavhandu-Ramarumo LG, Bessong PO. Immunologic, virologic and drug resistance outcomes in an HIV-infected prospective cohort on treatment in South Africa. PLoS One 2024; 19:e0307519. [PMID: 39186551 DOI: 10.1371/journal.pone.0307519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 07/05/2024] [Indexed: 08/28/2024] Open
Abstract
BACKGROUND In September 2016, South Africa introduced the Universal Test and Treat (UTT) programme to manage HIV infection. However, the development of drug resistance and sustaining viral suppression are challenges to the success of treatment programmes. This prospective observational study describes virologic, immunologic, and drug resistance profiles in a test and treat cohort in north-eastern South Africa. METHODS Five hundred and thirty-four HIV-1 positive antiretroviral naïve adults entering treatment programmes were enrolled between January 2016 and February 2018. Trends in CD4+ cell count, viral load, and drug resistance by examination of deep sequences were assessed at baseline and every three months, for 24 months. RESULTS Seventy-five percent were late initiators into ART (that is baseline CD4+ cell counts < 500 cells/microliter) and 16% were early initiators into ART and baseline CD4 was not available for 9%. Eleven percent (12/104) achieved immunological response after 6 months, 39.4% (41 /104) after 12 months, and 97.5% (101/104) after 24 months. Seventy-one percent (381/534) had baseline viral loads >1000 RNA copies/ml. Nine percent (22/246) achieved viral suppression after 3 months, 50% (122/246) after 6 months and 73.6% (181/246) after 12 months. A slower viral suppression was observed for males than females (p value = 0.012). A total of 45.6% (52/114) individuals had at least one drug resistance mutation (DRM) detected at >20% threshold in any of the time points, and the number increased to 55% (63/114) when minor variants were accounted for. Forty-eight percent (14/29) had drug resistance mutations at >5% threshold as early as 3 months into treatment. CONCLUSION The UNAIDS target of 95% viral suppression in individuals under treatment was not observed after 12 months of treatment, and this was less successful for males. Adherence and drug resistance monitoring could be beneficial for individuals harbouring resistant viruses early into treatment.
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Affiliation(s)
- Bixa Ogola
- SAMRC-UNIVEN Antimicrobial Resistance and Global Health Research Unit, HIV/AIDS & Global Health Research Programme, University of Venda, Thohoyandou, South Africa
| | - Nontokozo D Matume
- SAMRC-UNIVEN Antimicrobial Resistance and Global Health Research Unit, HIV/AIDS & Global Health Research Programme, University of Venda, Thohoyandou, South Africa
- Discipline of Genetics, School of Life Sciences, University of KwaZulu-Natal, Pietermaritzburg, South Africa
| | - Denis M Tebit
- SAMRC-UNIVEN Antimicrobial Resistance and Global Health Research Unit, HIV/AIDS & Global Health Research Programme, University of Venda, Thohoyandou, South Africa
- Global Biomed Scientific LLC, Forest, VA, United States of America
| | - Lufuno G Mavhandu-Ramarumo
- SAMRC-UNIVEN Antimicrobial Resistance and Global Health Research Unit, HIV/AIDS & Global Health Research Programme, University of Venda, Thohoyandou, South Africa
| | - Pascal Obong Bessong
- SAMRC-UNIVEN Antimicrobial Resistance and Global Health Research Unit, HIV/AIDS & Global Health Research Programme, University of Venda, Thohoyandou, South Africa
- Center for Global Health Equity, University of Virginia, Charlottesville, Virginia, United States of America
- School of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
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Browne EN, Stoner MCD, Kabudula C, Dufour MSK, Neilands TB, Leslie HH, West RL, Peacock D, Gómez-Olivé FX, Kahn K, Pettifor A, Lippman SA. Exploring the Relationship Between Anticipated Stigma and Community Shared Concerns about HIV on Defaulting from HIV Care in Rural South Africa. STIGMA AND HEALTH 2024; 9:173-180. [PMID: 38983717 PMCID: PMC11230650 DOI: 10.1037/sah0000475] [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] [Indexed: 07/11/2024]
Abstract
Although stigma has been associated with people living with HIV defaulting from care, there is a gap in understanding the specific impact of individual stigma and community-level concern about HIV on defaulting. Methods This is a secondary analysis of a unique dataset that links health facility-based medical records to a population-representative community survey conducted in 2018 in rural Mpumalanga province, South Africa. We used the parametric g-formula to estimate associations among individual anticipated stigma, low perceived community and local leader concern about HIV, and defaulting from care in the prior year. In addition, we estimated the population-level effects of intervening to reduce stigma and increase concern on defaulting. Results Among 319 participants on treatment, 42 (13.2%) defaulted from care during the prior year. Anticipated stigma (risk ratio [RR] 1.22, 95% confidence interval [CI]: 0.72, 2.74), low perceived concern about HIV/AIDS from community leadership (RR 1.12, 95% CI 0.76, 3.38), and low shared concerns about HIV/AIDS in the community (RR 1.37; 95% CI 0.79, 3.07) were not significantly associated with default. Hypothetical population intervention effects to remove individual anticipated stigma and low community concerns yielded small reductions in default (~1% reduction). Conclusions In this sample, we found limited impact of reducing anticipated stigma and increasing shared concern about HIV on retention in care. Future studies should consider the limitations of this study by examining the influence of other sources of stigma in more detail and assessing how perceptions of stigma and concern impact the full HIV testing and care cascade.
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Affiliation(s)
- Erica N Browne
- Women's Global Health Imperative, RTI International, Berkeley, CA, USA
| | - Marie C D Stoner
- Women's Global Health Imperative, RTI International, Berkeley, CA, USA
| | - Chodziwadziwa Kabudula
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mi-Suk Kang Dufour
- School of Public Health, Division of Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Torsten B Neilands
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Hannah H Leslie
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Rebecca L West
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
- Department of Global Health, Boston University School of Public Health
| | | | - F Xavier Gómez-Olivé
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Kathleen Kahn
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Audrey Pettifor
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Sheri A Lippman
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
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Kim HY, Inghels M, Mathenjwa T, Shahmanesh M, Seeley J, Matthews P, McGrath N, Adeagbo O, Gareta D, Yapa HM, Zuma T, Dobra A, Bärnighausen T, Tanser F. The impact of a conditional financial incentive on linkage to HIV care: Findings from the HITS cluster randomized clinical trial in rural South Africa. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.03.15.24304278. [PMID: 38562873 PMCID: PMC10984055 DOI: 10.1101/2024.03.15.24304278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
Introduction HIV elimination requires innovative approaches to ensure testing and immediate treatment provision. We investigated the effectiveness of conditional financial incentives on increasing linkage to HIV care in a 2×2 factorial cluster randomized controlled trial-Home-Based Intervention to Test and Start (HITS) - in rural South Africa. Methods Of 45 communities in uMkhanyakude, KwaZulu-Natal, 16 communities were randomly assigned to the arms to receive financial incentives for home-based HIV counseling and testing (HBHCT) and linkage to care within 6 weeks (R50 [US$3] food voucher each) and 29 communities to the arms without financial incentives. We examined linkage to care (i.e., initiation or resumption of antiretroviral therapy after >3 months of care interruption) at local clinics within 6 weeks of a home visit, the eligibility period to receive the second financial incentive. Linkage to care was ascertained from individual clinical records. Intention-to-treat analysis (ITT) was performed using modified Poisson regression with adjustment for receiving another intervention (i.e., male-targeted HIV-specific decision support app) and clustering of standard errors at the community level. Results Among 13,894 eligible men (i.e., ≥15 years and resident in the 45 communities), 20.7% received HBHCT, which resulted in 122 HIV-positive tests. Of these, 27 linked to care within 6 weeks of HBHCT. Additionally, of eligible men who did not receive HBHCT, 66 linked to care. In the ITT analysis, the proportion of linkage to care among men did not differ in the arms which received financial incentives and those without financial incentives (adjusted Risk Ratio [aRR]=0.78, 95% CI: 0.51-1.21). Among 19,884 eligible women, 29.1% received HBHCT, which resulted in 375 HIV-positive tests. Of these, 75 linked to care. Among eligible women who did not receive HBHCT, 121 linked to care within 6 weeks. Women in the financial incentive arms had a significantly higher probability of linkage to care, compared to those in the arms without financial incentives (aRR=1.50; 95% CI: 1.03-2.21). Conclusion While a small once-off financial incentive did not increase linkage to care among men during the eligibility period of 6 weeks, it significantly improved linkage to care among women over the same period. Clinical Trial Number: ClinicalTrials.gov # NCT03757104.
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Maskew M, Benade M, Huber A, Pascoe S, Sande L, Malala L, Manganye M, Rosen S. Patterns of engagement in care during clients' first 12 months after HIV treatment initiation in South Africa: A retrospective cohort analysis using routinely collected data. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0002956. [PMID: 38416789 PMCID: PMC10901315 DOI: 10.1371/journal.pgph.0002956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 02/02/2024] [Indexed: 03/01/2024]
Abstract
Retention on antiretroviral therapy (ART) during the early treatment period is one of the most serious challenges facing HIV programs, but the timing and patterns of early disengagement from care remain poorly understood. We describe patterns of engagement in HIV care during the first year after treatment initiation. We analysed retrospective datasets of routinely collected electronic medical register (EMR) data for ≥18-year-old clients who initiated ART at public sector clinics in South Africa after 01/01/2018 and had ≥14 months of potential follow-up. Using scheduled visit dates, we characterized engagement in care as continuous (no treatment interruption), cyclical (at least one visit >28 days late with a return visit observed) or disengaged (visit not attended and no evidence of return). We report 6- and 12-month patterns of retention in care and viral suppression. Among 35,830 participants (65% female, median age 33), in months 0-6, 59% were continuously in care, 14% had engaged cyclically, 11% had transferred to another facility, 1% had died, and 16% had disengaged from care at the initiating facility. Among disengagers in the first 6 months, 58% did not return after their initiation visit. By 12 months after initiation, the overall proportion disengaged was 23%, 45% were classified as continuously engaged in months 7-12, and only 38% of the cohort had maintained continuous engagement at both the 6- and 12-month endpoints. Participants who were cyclically engaged in months 0-6 were nearly twice as likely to disengage in months 7-12 as were continuous engagers in months 0-6 (relative risk 1.76, 95% CI:1.61-1.91) and were more likely to have an unsuppressed viral load by 12 months on ART (RR = 1.28; 95% CI1.13-1.44). The needs of continuous and cyclical engagers and those disengaging at different timepoints may vary and require different interventions or models of care.
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Affiliation(s)
- Mhairi Maskew
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mariet Benade
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
- Department of Medical Microbiology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Amy Huber
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Sophie Pascoe
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Linda Sande
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Lufuno Malala
- HIV & AIDS Treatment, Care and Support Directorate, HIV & AIDS and STI Cluster, National Department of Health, Pretoria, South Africa
| | - Musa Manganye
- HIV & AIDS Treatment, Care and Support Directorate, HIV & AIDS and STI Cluster, National Department of Health, Pretoria, South Africa
| | - Sydney Rosen
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
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Hamooya BM, Mutembo S, Muyunda B, Mweebo K, Kancheya N, Sikazwe L, Sakala M, Mvula J, Kunda S, Kabesha S, Cheelo C, Fwemba I, Banda C, Masenga SK. HIV test-and-treat policy improves clinical outcomes in Zambian adults from Southern Province: a multicenter retrospective cohort study. Front Public Health 2023; 11:1244125. [PMID: 37900026 PMCID: PMC10600392 DOI: 10.3389/fpubh.2023.1244125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 09/11/2023] [Indexed: 10/31/2023] Open
Abstract
Background Globally, most countries have implemented a test-and-treat policy to reduce morbidity and mortality associated with HIV infection. However, the impact of this strategy has not been critically appraised in many settings, including Zambia. We evaluated the retention and clinical outcomes of adults enrolled in antiretroviral therapy (ART) and assessed the impact of the test-and-treat policy. Methods We conducted a retrospective cohort study among 6,640 individuals who initiated ART between January 1, 2014 and July 31, 2016 [before test-and-treat cohort (BTT), n = 2,991] and between August 1, 2016 and October 1, 2020 [after test-and-treat cohort (ATT), n = 3,649] in 12 districts of the Southern province. To assess factors associated with retention, we used logistic regression (xtlogit model). Results The median age [interquartile range (IQR)] was 34.8 years (28.0, 42.1), and 60.2% (n = 3,995) were women. The overall retention was 83.4% [95% confidence interval (CI) 82.6, 84.4], and it was significantly higher among the ATT cohort, 90.6 vs. 74.8%, p < 0.001. The reasons for attrition were higher in the BTT compared to the ATT cohorts: stopped treatment (0.3 vs. 0.1%), transferred out (9.3 vs. 3.2%), lost to follow-up (13.5 vs. 5.9%), and death (1.4 vs. 0.2%). Retention in care was significantly associated with the ATT cohort, increasing age and baseline body mass index (BMI), rural residence, and WHO stage 2, while non-retention was associated with never being married, divorced, and being in WHO stage 3. Conclusion The retention rate and attrition factors improved in the ATT compared to the BTT cohorts. Drivers of retention were test-and-treat policy, older age, high BMI, rural residence, marital status, and WHO stage 1. Therefore, there is need for interventions targeting young people, urban residents, non-married people, and those in the symptomatic WHO stages and with low BMI. Our findings highlight improved ART retention after the implementation of the test-and-treat policy.
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Affiliation(s)
- Benson M. Hamooya
- School of Medicine and Health Sciences, Mulungushi University, Livingstone, Zambia
| | - Simon Mutembo
- International Vaccine Access Center, Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, United States
| | - Brian Muyunda
- Centers for Disease Control and Prevention, Lusaka, Zambia
| | - Keith Mweebo
- Centers for Disease Control and Prevention, Lusaka, Zambia
| | - Nzali Kancheya
- Centers for Disease Control and Prevention, Lusaka, Zambia
| | - Lyapa Sikazwe
- Provincial Medical Office, Ministry of Health, Choma, Zambia
| | - Morgan Sakala
- Provincial Medical Office, Ministry of Health, Choma, Zambia
| | - Johanzi Mvula
- Provincial Medical Office, Ministry of Health, Choma, Zambia
| | - Salazeh Kunda
- Provincial Medical Office, Ministry of Health, Choma, Zambia
| | - Shem Kabesha
- Provincial Medical Office, Ministry of Health, Choma, Zambia
| | - Chilala Cheelo
- School of Medicine and Health Sciences, Mulungushi University, Livingstone, Zambia
| | - Isaac Fwemba
- School of Public Health, University of Zambia, Lusaka, Zambia
| | - Clive Banda
- Provincial Medical Office, Ministry of Health, Choma, Zambia
| | - Sepiso K. Masenga
- School of Medicine and Health Sciences, Mulungushi University, Livingstone, Zambia
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Dovel K, Balakasi K, Hubbard J, Phiri K, Nichols BE, Coates TJ, Kulich M, Chikuse E, Phiri S, Long LC, Hoffman RM, Choko AT. Identifying efficient linkage strategies for men (IDEaL): a study protocol for an individually randomised control trial. BMJ Open 2023; 13:e070896. [PMID: 37438067 DOI: 10.1136/bmjopen-2022-070896] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/14/2023] Open
Abstract
INTRODUCTION Men in sub-Saharan Africa are less likely than women to initiate antiretroviral therapy (ART) and more likely to have longer cycles of disengagement from ART programmes. Treatment interventions that meet the unique needs of men are needed, but they must be scalable. We will test the impact of various interventions on 6-month retention in ART programmes among men living with HIV who are not currently engaged in care (never initiated ART and ART clients with treatment interruption). METHODS AND ANALYSIS We will conduct a programmatic, individually randomised, non-blinded, controlled trial. 'Non-engaged' men will be randomised 1:1:1 to either a low-intensity, high-intensity or stepped arm. The low-intensity intervention includes one-time male-specific counseling+facility navigation only. The high-intensity intervention offers immediate outside-facility ART initiation+male-specific counselling+facility navigation for follow-up ART visits. In the stepped arm, intervention activities build in intensity over time for those who do not re-engage in care with the following steps: (1) one-time male-specific counselling+facility navigation→(2) ongoing male mentorship+facility navigation→(3) outside-facility ART initiation+male-specific counselling+facility navigation for follow-up ART visits. Our primary outcome is 6-month retention in care. Secondary outcomes include cost-effectiveness and rates of adverse events. The primary analysis will be intention to treat with all eligible men in the denominator and all men retained in care at 6 months in the numerator. The proportions achieving the primary outcome will be compared with a risk ratio, corresponding 95% CI and p value computed using binomial regression accounting for clustering at facility level. ETHICS AND DISSEMINATION The Institutional Review Board of the University of California, Los Angeles and the National Health Sciences Research Council in Malawi have approved the trial protocol. Findings will be disseminated rapidly in national and international forums and in peer-reviewed journals and are expected to provide urgently needed information to other countries and donors. TRIAL REGISTRATION NUMBER NCT05137210. DATE AND VERSION 5 May 2023; version 3.
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Affiliation(s)
- Kathryn Dovel
- Division of Infectious Diseases, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
- Department of Implementation Science, Partners in Hope, Lilongwe, Malawi
| | - Kelvin Balakasi
- Department of Implementation Science, Partners in Hope, Lilongwe, Malawi
| | - Julie Hubbard
- Division of Infectious Diseases, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Khumbo Phiri
- Department of Implementation Science, Partners in Hope, Lilongwe, Malawi
| | - Brooke E Nichols
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
- Department of Medical Microbiology, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, Netherlands
- Foundation for Innovative New Diagnostics (FIND), Geneva, Switzerland
| | - Thomas J Coates
- Division of Infectious Diseases, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
- Global Health Institute, University of California, San Francisco, California, USA
| | - Michal Kulich
- Department of Probability and Statistics, Faculty of Mathematics and Physics, Charles University, Prague, Czechia
| | - Elijah Chikuse
- Department of Implementation Science, Partners in Hope, Lilongwe, Malawi
| | - Sam Phiri
- Department of Implementation Science, Partners in Hope, Lilongwe, Malawi
| | - Lawrence C Long
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Risa M Hoffman
- Division of Infectious Diseases, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Augustine T Choko
- Clinical Research Programme, Malawi Liverpool Wellcome Programme, Blantyre, Malawi
- Liverpool School of Tropical Medicine, Liverpool, UK
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Iwuji CC, Baisley K, Maoyi ML, Orievulu K, Mazibuko L, Ayeb-Karlsson S, Yapa HM, Hanekom W, Herbst K, Kniveton D. The Impact of Drought on HIV Care in Rural South Africa: An Interrupted Time Series Analysis. ECOHEALTH 2023; 20:178-193. [PMID: 37523018 PMCID: PMC10613144 DOI: 10.1007/s10393-023-01647-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 04/23/2023] [Accepted: 05/13/2023] [Indexed: 08/01/2023]
Abstract
This analysis investigates the relationship between drought and antiretroviral treatment (ART) adherence and retention in HIV care in the Hlabisa sub-district, KwaZulu-Natal, South Africa. Data on drought and ART adherence and retention were collated for the study period 2010-2019. Drought was quantified using the 3-month Standard Precipitation Evapotranspiration Index (SPEI) and Standard Precipitation Index (SPI) from station data. Adherence, proxied by the Medication Possession Ratio (MPR), and retention data were obtained from the public ART programme database. MPR and retention were calculated from individuals aged 15-59 years who initiated ART between January 2010 and December 2018 and visited clinic through February 2019. Between 01 January 2010 and 31 December 2018, 40,714 individuals started ART in the sub-district and made 1,022,760 ART visits. The SPI showed that 2014-2016 were dry years, with partial recovery after 2016 in the wet years. In the period from 2010 to 2012, mean 6-month MPR increased from 0.85 in July 2010 to a high of 0.92 in December 2012. MPR then decreased steadily through 2013 and 2014 to 0.78 by December 2014. The mean proportion retained in care 6 months after starting ART showed similar trends to MPR, increasing from 86.9% in July 2010 to 91.4% in December 2012. Retention then decreased through 2013, with evidence of a pronounced drop in January 2014 when the odds of retention decreased by 30% (OR = 0.70, CI = 0.53-0.92, P = 0.01) relative to the end of 2013. Adherence and retention in care decreased during the drought years.
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Affiliation(s)
- Collins C Iwuji
- Africa Health Research Institute, Mtubatuba, KwaZulu-Natal, South Africa.
- Department of Global Health & Infection, Brighton and Sussex Medical School, University of Sussex, Falmer, Brighton, BN1 9PX, UK.
| | - Kathy Baisley
- Africa Health Research Institute, Mtubatuba, KwaZulu-Natal, South Africa
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Molulaqhooa Linda Maoyi
- DSI-MRC South African Population Research Infrastructure Network (SAPRIN), Johannesburg, South Africa
| | - Kingsley Orievulu
- Africa Health Research Institute, Mtubatuba, KwaZulu-Natal, South Africa
- Department of Global Health & Infection, Brighton and Sussex Medical School, University of Sussex, Falmer, Brighton, BN1 9PX, UK
- Centre for Africa-China Studies, University of Johannesburg, Johannesburg, South Africa
| | - Lusanda Mazibuko
- Africa Health Research Institute, Mtubatuba, KwaZulu-Natal, South Africa
| | - Sonja Ayeb-Karlsson
- Department of Global Health & Infection, Brighton and Sussex Medical School, University of Sussex, Falmer, Brighton, BN1 9PX, UK
- Institute for Risk and Disaster Reduction, University College London, London, UK
- United Nations University Institute for Environment and Human Security, Bonn, Germany
| | - H Manisha Yapa
- Kirby Institute for Infection and Immunity, University of New South Wales Sydney, Sydney, Australia
- Central Clinical School, University of Sydney, Sydney, Australia
| | - Willem Hanekom
- Africa Health Research Institute, Mtubatuba, KwaZulu-Natal, South Africa
- Division of Infection and Immunity, University College London, London, UK
| | - Kobus Herbst
- Africa Health Research Institute, Mtubatuba, KwaZulu-Natal, South Africa
- DSI-MRC South African Population Research Infrastructure Network (SAPRIN), Johannesburg, South Africa
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8
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Choko AT, Coates TJ, Mphande M, Balakasi K, Robson I, Phiri K, Phiri S, Kulich M, Sweat M, Cornell M, Hoffman RM, Dovel K. Engaging men through HIV self-testing with differentiated care to improve ART initiation and viral suppression among men in Malawi (ENGAGE): A study protocol for a randomized control trial. PLoS One 2023; 18:e0281472. [PMID: 36827327 PMCID: PMC9956026 DOI: 10.1371/journal.pone.0281472] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 01/22/2023] [Indexed: 02/25/2023] Open
Abstract
BACKGROUND Men experience twice the mortality of women while on ART in sub-Saharan Africa (SSA) largely due to late HIV diagnosis and poor retention. Here we propose to conduct an individually randomized control trial (RCT) to investigate the impact of three-month home-based ART (hbART) on viral suppression among men who were not engaged in care. METHODS AND DESIGN A programmatic, individually randomized non-blinded, non-inferiority-controlled trial design (ClinicalTrials.org NCT04858243). Through medical chart reviews we will identify "non-engaged" men living with HIV, ≥15years of age who are not currently engaged in ART care, including (1) men who have tested HIV-positive and have not initiated ART within 7 days; (2) men who have initiated ART but are at risk of immediate default; and (3) men who have defaulted from ART. With 1:1 computer block randomization to either hbART or facility-based ART (fbART) arms, we will recruit men from 10-15 high-burden health facilities in central and southern Malawi. The hbART intervention will consist of 3 home-visits in a 3-month period by a certified male study nurse ART provider. In the fbART arm, male participants will be offered counselling at male participant's home, or a nearby location that is preferred by participants, followed with an escort to the local health facility and facility navigation. The primary outcome is the proportion of men who are virally suppressed at 6-months after ART initiation. Assuming primary outcome achievement of 24.0% and 33.6% in the two arms, 350 men per arm will provide 80% power to detect the stated difference. DISCUSSION Identifying effective ART strategies that are convenient and accessible for men in SSA is a priority in the HIV world. Men may not (re-)engage in facility-based care due to a myriad of barriers. Two previous trials investigated the impact of hbART on viral suppression in the general population whereas this trial focuses on men. Additionally, this trial involves a longer duration of hbART i.e., three months compared to two weeks allowing men more time to overcome the initial psychological denial of taking ART.
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Affiliation(s)
- Augustine T. Choko
- Partners in Hope, Lilongwe, Malawi
- College of Medicine, University of Malawi, Blantyre, Malawi
| | - Thomas J. Coates
- David Geffen School of Medicine, Division of Infectious Diseases, Los Angeles, California, United States of America
| | | | | | | | | | | | - Michal Kulich
- Department of Probability and Statistics, Faculty of Mathematics and Physics, Charles University, Prague, Czech Republic
| | - Michael Sweat
- Department of Psychiatry and Behavioral Sciences, College of Medicine, Medical University of South Carolina, Charleston, South Carolina, United States of America
| | - Morna Cornell
- Centre for Infectious Disease Epidemiology & Research, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Risa M. Hoffman
- David Geffen School of Medicine, Division of Infectious Diseases, Los Angeles, California, United States of America
| | - Kathryn Dovel
- Partners in Hope, Lilongwe, Malawi
- David Geffen School of Medicine, Division of Infectious Diseases, Los Angeles, California, United States of America
- * E-mail:
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9
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Attrition from Care Among Men Initiating ART in Male-Only Clinics Compared with Men in General Primary Healthcare Clinics in Khayelitsha, South Africa: A Matched Propensity Score Analysis. AIDS Behav 2023; 27:358-369. [PMID: 35908271 PMCID: PMC9852215 DOI: 10.1007/s10461-022-03772-9] [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] [Accepted: 06/25/2022] [Indexed: 01/24/2023]
Abstract
Men have higher rates of attrition from antiretroviral therapy (ART) programs than women. In Khayelitsha, a high HIV prevalence area in South Africa, two public sector primary healthcare clinics offer services, including HIV testing and treatment, exclusively to men. We compared attrition from ART care among men initiating ART at these clinics with male attrition in six general primary healthcare clinics in Khayelitsha. We described baseline characteristics of patients initiating ART at the male and general clinics from 1 January 2014 to 31 March 2018. We used exposure propensity scores (generated based on baseline health and age) to match male clinic patients 1:1 to males at other clinics. The association between attrition (death or loss to follow-up, defined as no visits for nine months) and clinic type was estimated using Cox proportional hazards regression. Follow-up time began at ART initiation and ended at attrition, clinic transfer, or dataset closure. Before matching, patients from male clinics (n = 784) were younger than males from general clinics (n = 2726), median age: 31.2 vs 35.5 years. Those initiating at male clinics had higher median CD4 counts at ART initiation [Male Clinic 1: 329 (IQR 210-431), Male Clinic 2: 364 (IQR 260-536), general clinics 258 (IQR 145-398), cells/mm3]. In the matched analysis (1451 person-years, 1568 patients) patients initiating ART at male clinics had lower attrition (HR 0.71; 95% CI 0.60-0.85). In separate analyses for each of the two male clinics, only the more established male clinic showed a protective effect. Male-only clinics reached younger, healthier men, and had lower ART attrition than general services. These findings support clinic-specific adaptations to create more male-friendly environments.
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Van Heerden A, Humphries H, Geng E. Whole person HIV services: a social science approach. Curr Opin HIV AIDS 2023; 18:46-51. [PMID: 36440805 PMCID: PMC9799045 DOI: 10.1097/coh.0000000000000773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
PURPOSE OF REVIEW Globally, approximately 38.4 million people who are navigating complex lives, are also living with HIV, while HIV incident cases remain high. To improve the effectiveness of HIV prevention and treatment service implementation, we need to understand what drives human behaviour and decision-making around HIV service use. This review highlights current thinking in the social sciences, emphasizing how understanding human behaviour can be leveraged to improve HIV service delivery. RECENT FINDINGS The social sciences offer rich methodologies and theoretical frameworks for investigating how factors synergize to influence human behaviour and decision-making. Social-ecological models, such as the Behavioural Drivers Model (BDM), help us conceptualize and investigate the complexity of people's lives. Multistate and group-based trajectory modelling are useful tools for investigating the longitudinal nature of peoples HIV journeys. Successful HIV responses need to leverage social science approaches to design effective, efficient, and high-quality programmes. SUMMARY To improve our HIV response, implementation scientists, interventionists, and public health officials must respond to the context in which people make decisions about their health. Translating biomedical efficacy into real-world effectiveness is not simply finding a way around contextual barriers but rather engaging with the social context in which communities use HIV services.
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Affiliation(s)
- Alastair Van Heerden
- Centre for Community Based Research, Human Sciences Research Council, Pietermaritzburg
- SAMRC/Wits Developmental Pathways for Health Research Unit, University of the Witwatersrand, Johannesburg
| | - Hilton Humphries
- Centre for Community Based Research, Human Sciences Research Council, Pietermaritzburg
- Department of Psychology, School of Applied Human Sciences, University of KwaZulu-Natal, Pietermaritzburg, South Africa
| | - Elvin Geng
- Centre for Dissemination and Implementation, Institute of Public Health, Division of Infectious Diseases, Department of Medicine, School of Medicine at Washington University in St. Louis, St. Louis, Missouri, USA
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11
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Achieving the UNAIDS 90-90-90 targets: a comparative analysis of four large community randomised trials delivering universal testing and treatment to reduce HIV transmission in sub-Saharan Africa. BMC Public Health 2022; 22:2333. [PMID: 36514036 PMCID: PMC9746009 DOI: 10.1186/s12889-022-14713-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 11/23/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Four large community-randomized trials examining universal testing and treatment (UTT) to reduce HIV transmission were conducted between 2012-2018 in Botswana, Kenya, Uganda, Zambia and South Africa. In 2014, the UNAIDS 90-90-90 targets were adopted as a useful metric to monitor coverage. We systematically review the approaches used by the trials to measure intervention delivery, and estimate coverage against the 90-90-90 targets. We aim to provide in-depth understanding of the background contexts and complexities that affect estimation of population-level coverage related to the 90-90-90 targets. METHODS Estimates were based predominantly on "process" data obtained during delivery of the interventions which included a combination of home-based and community-based services. Cascade coverage data included routine electronic health records, self-reported data, survey data, and active ascertainment of HIV viral load measurements in the field. RESULTS The estimated total adult populations of trial intervention communities included in this study ranged from 4,290 (TasP) to 142,250 (Zambian PopART Arm-B). The estimated total numbers of PLHIV ranged from 1,283 (TasP) to 20,541 (Zambian PopART Arm-B). By the end of intervention delivery, the first-90 target (knowledge of HIV status among all PLHIV) was met by all the trials (89.2%-94.0%). Three of the four trials also achieved the second- and third-90 targets, and viral suppression in BCPP and SEARCH exceeded the UNAIDS target of 73%, while viral suppression in the Zambian PopART Arm-A and B communities was within a small margin (~ 3%) of the target. CONCLUSIONS All four UTT trials aimed to implement wide-scale testing and treatment for HIV prevention at population level and showed substantial increases in testing and treatment for HIV in the intervention communities. This study has not uncovered any one estimation approach which is superior, rather that several approaches are available and researchers or policy makers seeking to measure coverage should reflect on background contexts and complexities that affect estimation of population-level coverage in their specific settings. All four trials surpassed UNAIDS targets for universal testing in their intervention communities ahead of the 2020 milestone. All but one of the trials also achieved the 90-90 targets for treatment and viral suppression. UTT is a realistic option to achieve 95-95-95 by 2030 and fast-track the end of the HIV epidemic.
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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: 6] [Impact Index Per Article: 3.0] [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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13
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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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Bantie B, Seid A, Kerebeh G, Alebel A, Dessie G. Loss to follow-up in "test and treat era" and its predictors among HIV-positive adults receiving ART in Northwest Ethiopia: Institution-based cohort study. Front Public Health 2022; 10:876430. [PMID: 36249247 PMCID: PMC9557930 DOI: 10.3389/fpubh.2022.876430] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 08/29/2022] [Indexed: 01/21/2023] Open
Abstract
Background People living with HIV/AIDS are enrolled in lifelong Anti-Retroviral Treatment (ART) irrespective of their clinical staging as well as CD4 cell count. Although this "Universal Test and Treat" strategy of ART was found to have numerous benefits, loss from follow-up and poor retention remained a long-term challenge for the achievement of ART program targets. Hence, this study is aimed at addressing the much-needed effect of the test and treat strategy on the incidence of loss to follow-up (LTFU) in Ethiopia. Method and materials An institution-based follow-up study was conducted on 513 adults (age ≥15) who enrolled in ART at a public health institution in Bahir Dar City, Northwest Ethiopia. Data were extracted from the charts of selected patients and exported to Stata 14.2 software for analysis. Basic socio-demographic, epidemiological, and clinical characteristics were described. The Kaplan-Meier curve was used to estimate the loss to follow-up free (survival) probability of HIV-positive adults at 6, 12, 24, and 48 months of ART therapy. We fitted a multivariable Cox model to determine the statistically significant predictors of LTFU. Result The incidence density of LTFU was 9.7 per 100 person-years of observation (95% CI: 7.9-11.9 per 100 PYO). Overall, LTFU is higher in the rapid ART initiation (24% in rapid initiated vs. 11.3% in lately initiated, AHR 2.08, P = 0.004), in males (23% males vs. 14.7% females, AHR1.96, P = 0.004), in singles (34% single vs. 11% married, with AHR1.83, P = 0.044), in non-disclosed HIV-status (33% non-disclosed 11% disclosed, AHR 2.00 p = 0.001). Patients with poor/fair ART adherence were also identified as another risk group of LTFU (37% in poor vs. 10.5% in good adherence group, AHR 4.35, P = 0.001). Conclusion The incidence of LTFU in this universal test and treat era was high, and the highest figure was observed in the first 6 months. Immediate initiation of ART in a universal test and treat strategy shall be implemented cautiously to improve patient retention and due attention shall be given to those high-risk patients.
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Affiliation(s)
- Berihun Bantie
- Department of Adult Health Nursing, College of Medicine and Health Science, Debre Tabor University, Debre Tabor, Ethiopia,*Correspondence: Berihun Bantie
| | - Awole Seid
- Department of Adult Health Nursing, School of Health Science, College of Medicine and Health Science, Bahir Dar University, Bahir Dar, Ethiopia
| | - Gashaw Kerebeh
- Department of Pediatrics and Child Health Nursing, College of Medicine and Health Science, Debre Tabor University, Debre Tabor, Ethiopia
| | - Animut Alebel
- School of Public Health, Faculty of Health, University of Technology Sydney, Ultimo, NSW, Australia
| | - Getenet Dessie
- Department of Adult Health Nursing, School of Health Science, College of Medicine and Health Science, Bahir Dar University, Bahir Dar, Ethiopia
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Jonas K, Zani B, Ramraj T, Chirinda W, Jama N, Basera W, McClinton Appollis T, Pass D, Govindasamy D, Mukumbang FC, Mathews C, Nicol E. Service delivery models for enhancing linkage to and retention in HIV care services for adolescent girls and young women and adolescent boys and young men: a protocol for an overview of systematic reviews. BMJ Open 2022; 12:e060778. [PMID: 36123080 PMCID: PMC9486299 DOI: 10.1136/bmjopen-2022-060778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Recent advances in the HIV care continuum have shown that an individual diagnosed with HIV should be initiated on antiretroviral therapy as soon as possible regardless of the CD4 count levels and retained in HIV care services. Studies have reported large losses in the HIV continuum of care, before and after the era of universal test and treat. Several systematic reviews have reported on the strategies for improving linkage to and retention in HIV treatment and care. The purpose of this overview of systematic reviews is to identify HIV care interventions or service delivery models (SDMs) and synthesise evidence on the effects of these to link adolescent girls and young women (AGYW) and adolescent boys and young men (ABYM) to care and retain them in care. We also aim to highlight gaps in the evidence on interventions and SDMs to improve linkage and retention in HIV care of AGYW and ABYM. METHODS AND ANALYSIS An electronic search of four online databases: PubMed, Cochrane Database of Systematic Reviews, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Web of Science will be performed to identify systematic reviews on the effects of linkage to and retention in HIV care interventions or SDMs for AGYW aged 15-24 years and ABYM aged 15-35 years. Our findings on the effects of interventions and SDMs will be interpreted considering the intervention and or SDMs' effectiveness by the time period, setting and population of interest. Two or more authors will independently screen articles for inclusion using a priori criteria. ETHICS AND DISSEMINATION Ethics approval is not required for this study as only published secondary data will be used. Our findings will be disseminated through peer-reviewed publication, conference abstracts and through presentations to stakeholders and other community fora. The findings from this overview of systematic reviews will inform mixed-methods operations research on HIV intervention programming and delivery of HIV care services for AGYW and ABYM in South Africa. PROSPERO REGISTRATION NUMBER CRD42020177933.
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Affiliation(s)
- Kim Jonas
- Health Systems Research, South African Medical Research Council, Parow, South Africa
- Adolescent Health Research, University of Cape Town, Rondebosch, Western Cape, South Africa
| | - Babalwa Zani
- Knowledge Translation Unit, University of Cape Town Lung Institute, Rondebosch, Western Cape, South Africa
| | - Trisha Ramraj
- Health Systems Research Unit, South African Medical Research Council Durban, Durban, KwaZulu-Natal, South Africa
- HIV Prevention Research Unit, South African Medical Research Council Durban, Durban, KwaZulu-Natal, South Africa
| | - Witness Chirinda
- Burden of Disease Research, South African Medical Research Council, Tygerberg, South Africa
| | - Ngcwalisa Jama
- Burden of Disease Research, South African Medical Research Council, Tygerberg, South Africa
| | - Wisdom Basera
- Burden of Disease Research, South African Medical Research Council, Tygerberg, South Africa
| | | | - Desiree Pass
- Burden of Disease Research, South African Medical Research Council, Tygerberg, South Africa
| | - Darshini Govindasamy
- Health Systems Research, South African Medical Research Council, Parow, South Africa
| | | | - Catherine Mathews
- Health Systems Research, South African Medical Research Council, Parow, South Africa
- Adolescent Health Research, University of Cape Town, Rondebosch, Western Cape, South Africa
| | - Edward Nicol
- Burden of Disease Research, South African Medical Research Council, Tygerberg, South Africa
- University of Stellenbosch, Stellenbosch, Western Cape, South Africa
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Nshimirimana C, Ndayizeye A, Smekens T, Vuylsteke B. Loss to follow-up of patients in HIV care in Burundi: A retrospective cohort study. Trop Med Int Health 2022; 27:574-582. [PMID: 35411666 DOI: 10.1111/tmi.13753] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE The objective was to assess the loss to follow-up (LTFU) rates and associated factors amongst patients in HIV care in Burundi. METHODS We conducted a retrospective cohort study in HIV-positive patients aged ≥15 years who started antiretroviral therapy (ART) between January 2015 and July 2020, with 31 December 2020 as the end point. The outcome of LTFU was defined as failure of a patient to report for drug refill within 90 days from the last appointment. Study data were extracted from the national AIDS Info database. The LTFU proportion was determined using the Kaplan-Meier method with the log-rank test, whereas LTFU risk factors were explored using the Cox regression model. RESULTS A total of 29,829 patients on ART were included in the analysis. Cumulative incidence of LTFU was 2.3% at 12 months, 6.5% at 24 months, 12.7% at 36 months, 19.0% at 48 months, 24.1% at 60 months and 25.3% at 72 months. The overall LTFU incidence rate was 11.2 per 100 person-years of observation. The risk of LTFU was higher amongst patients who started ART after 2016 (adjusted hazard ratio [aHR] 1.75, 95% confidence interval [CI] 1.65-1.85) or within 7 days after diagnosis (aHR 1.27, 95% CI 1.21-1.35). CONCLUSION Our findings demonstrate the relatively high incidence of LTFU in the Burundi HIV programme. Interventions targeting patients with risk factors for LTFU are particularly necessary.
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Affiliation(s)
| | - Aimé Ndayizeye
- HIV/STIs Burundi National Program, Ministry of Public Health, Bujumbura, Burundi
| | - Tom Smekens
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Bea Vuylsteke
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
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Matthews LT, Psaros C, Mathenjwa M, Mosery N, Greener LR, Khidir H, Hovey JR, Pratt MC, Harrison A, Bennett K, Bangsberg DR, Smit JA, Safren SA. Demonstration and acceptability of a safer conception intervention for men with HIV in South Africa (Preprint). JMIR Form Res 2021; 6:e34262. [PMID: 35507406 PMCID: PMC9118009 DOI: 10.2196/34262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 02/24/2022] [Accepted: 03/16/2022] [Indexed: 12/03/2022] Open
Abstract
Background Many men with HIV (MWH) want to have children. HIV viral suppression minimizes sexual HIV transmission risks while allowing for conception and optimization of the health of men, their partners, and their infants. Objective This study developed and evaluated the feasibility and acceptability of an intervention to promote serostatus disclosure, antiretroviral therapy (ART) uptake and adherence, and viral suppression among MWH who want to have children in South Africa. Methods We developed a safer conception intervention (Sinikithemba Kwabesilisa or We give hope to men) to promote viral suppression via ART uptake and adherence, HIV serostatus disclosure, and other safer conception strategies for MWH in South Africa. Through 3 counseling and 2 booster sessions over 12 weeks, we offered education on safer conception strategies and aided participants in developing a safer conception plan. We recruited MWH (HIV diagnosis known for >1 month), not yet accessing ART or accessing ART for <3 months, in a stable partnership with an HIV-negative or unknown-serostatus woman, and wanting to have a child in the following year. We conducted an open pilot study to evaluate acceptability based on patient participation and exit interviews and feasibility based on recruitment and retention. In-depth exit interviews were conducted with men to explore intervention acceptability. Questionnaires collected at baseline and exit assessed disclosure outcomes; CD4 and HIV-RNA data were used to evaluate preliminary impacts on clinical outcomes of interest. Results Among 31 eligible men, 16 (52%) enrolled in the study with a median age of 29 (range 27-44) years and a median time-since-diagnosis of 7 months (range 1 month to 9 years). All identified as Black South African, with 56% (9/16) reporting secondary school completion and 44% (7/16) reporting full-time employment. Approximately 44% (7/16) of participants reported an HIV-negative (vs unknown-serostatus) partner. Approximately 88% (14/16) of men completed the 3 primary counseling sessions. In 11 exit interviews, men reported personal satisfaction with session content and structure while also suggesting that they would refer their peers to the program. They also described the perceived effectiveness of the intervention and self-efficacy to benefit. Although significance testing was not conducted, 81% (13/16) of men were taking ART at the exit, and 100% (13/13) of those on ART were virally suppressed at 12 weeks. Of the 16 men, 12 (75%) reported disclosure to pregnancy partners. Conclusions These preliminary data suggest that safer conception care is acceptable to men and has the potential to reduce HIV incidence among women and their children while supporting men’s health. Approximately half of the men who met the screening eligibility criteria were enrolled. Accordingly, refinement to optimize uptake is needed. Providing safer conception care and peer support at the community level may help reach men. Trial Registration ClinicalTrials.gov NCT03818984; https://clinicaltrials.gov/ct2/show/NCT03818984 International Registered Report Identifier (IRRID) RR2-https://doi.org/10.1007/s10461-017-1719-4
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Affiliation(s)
- Lynn T Matthews
- Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Christina Psaros
- Behavioral Medicine Program, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Mxolisi Mathenjwa
- MatCH Research Unit, Department of Obstetrics and Gynaecology, University of the Witwatersrand, Durban, South Africa
| | - Nzwakie Mosery
- MatCH Research Unit, Department of Obstetrics and Gynaecology, University of the Witwatersrand, Durban, South Africa
| | - Letitia Rambally Greener
- MatCH Research Unit, Department of Obstetrics and Gynaecology, University of the Witwatersrand, Durban, South Africa
- Population Services International, Johannesburg, South Africa
| | - Hazar Khidir
- Harvard Combined Residency Program in Emergency Medicine, Boston, MA, United States
| | - Jacquelyn R Hovey
- School of Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Madeline C Pratt
- Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Abigail Harrison
- Department of Behavioral and Social Sciences, School of Public Health, Brown University, Providence, RI, United States
| | - Kara Bennett
- Bennett Statistical Consulting, Ballston Lake, NY, United States
| | - David R Bangsberg
- School of Public Health, Oregon Health Sciences University - Portland State University, Portland, OR, United States
| | - Jennifer A Smit
- MatCH Research Unit, Department of Obstetrics and Gynaecology, University of the Witwatersrand, Durban, South Africa
| | - Steven A Safren
- Department of Psychology, University of Miami, Miami, FL, United States
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18
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Bengtson AM, Espinosa Dice AL, Kirwa K, Cornell M, Colvin CJ, Lurie MN. Patient Transfers and Their Impact on Gaps in Clinical Care: Differences by Gender in a Large Cohort of Adults Living with HIV on Antiretroviral Therapy in South Africa. AIDS Behav 2021; 25:3337-3346. [PMID: 33609203 DOI: 10.1007/s10461-021-03191-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/08/2021] [Indexed: 01/14/2023]
Abstract
For people living with HIV (PLWH), patient transfers may affect engagement in care. We followed a cohort of PLWH in Cape Town, South Africa who tested positive for HIV in 2012-2013 from ART initiation in 2012-2016 through December 2016. Patient transfers were defined as moving from one healthcare facility to another on a different day, considering all healthcare visits and recorded HIV-visits only. We estimated incidence rates (IR) for transfers by time since ART initiation, overall and by gender, and associations between transfers and gaps of > 180 days in clinical care. Overall, 4,176 PLWH were followed for a median of 32 months, and 8% (HIV visits)-17% (all healthcare visits) of visits were patient transfers. Including all healthcare visits, transfers were highest through 3 months on ART (IR 20.2 transfers per 100 visits, 95% CI 19.2-21.2), but increased through 36 months on ART when only HIV visits were included (IR 9.7, 95% CI 8.8-10.8). Overall, women were more likely to transfer than men, and transfers were associated with gaps in care (IR ratio [IRR] 3.06 95% CI 2.83-3.32; HIV visits only). In this cohort, patient transfers were frequent, more common among women, and associated with gaps in care.
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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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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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Matthews LT, Greener L, Khidir H, Psaros C, Harrison A, Mosery FN, Mathenjwa M, O’Neil K, Milford C, Safren SA, Bangsberg DR, Smit JA. "It really proves to us that we are still valuable": Qualitative research to inform a safer conception intervention for men living with HIV in South Africa. PLoS One 2021; 16:e0240990. [PMID: 33765001 PMCID: PMC7993862 DOI: 10.1371/journal.pone.0240990] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 10/06/2020] [Indexed: 11/25/2022] Open
Abstract
Objective Many men living with HIV want to have children. Opportunities to reduce periconception HIV transmission include antiretroviral therapy as prevention, pre-exposure prophylaxis, limiting condomless sex to peak fertility, and sperm processing. Whether men have knowledge of or want to adopt these strategies remains unknown. Methods We conducted focus group discussions (FGDs) with men accessing HIV care in South Africa in 2014 to inform a safer conception intervention for men. Eligible men were 25–45 years old, living with HIV, not yet accessing treatment, and wanting to have a child with an HIV-negative or unknown serostatus female partner (referred to as the “desired pregnancy partner”). FGDs explored motivations for having a healthy baby, feasibility of a clinic-based safer conception intervention, and acceptability of safer conception strategies. Data were analyzed using thematic analysis. Results Twelve participants from three FGDs had a median age of 37 (range 23–45) years, reported a median of 2 (range 1–4) sexual partners, and 1 (range 1–3) desired pregnancy partner(s). A third (N = 4) had disclosed HIV-serostatus to the pregnancy partner. Emergent themes included opportunities for and challenges to engaging men in safer conception services. Opportunities included enthusiasm for a clinic-based safer conception intervention and acceptance of some safer conception strategies. Challenges included poor understanding of safer conception strategies, unfamiliarity with risk reduction [versus “safe” (condoms) and “unsafe” (condomless) sex], mixed acceptability of safer conception strategies, and concerns about disclosing HIV-serostatus to a partner. Conclusions Men living with HIV expressed interest in safer conception and willingness to attend clinic programs. Imprecise prevention counseling messages make it difficult for men to conceptualize risk reduction. Effective safer conception programs should embrace clear language, e.g. undetectable = untransmittable (U = U), and support multiple approaches to serostatus disclosure to pregnancy partners.
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Affiliation(s)
- Lynn T. Matthews
- University of Alabama at Birmingham, Birmingham, AL, United States of America
- Center for Global Health and Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, United States of America
- * E-mail:
| | - Letitia Greener
- Department of Obstetrics and Gynaecology, MRU (MatCH), University of the Witwatersrand, Faculty of Health Sciences, Durban, South Africa
- Wits Reproductive Health and HIV Institute (Wits RHI), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Hazar Khidir
- Harvard Medical School, Massachusetts General Hospital, Brigham and Women’s Hospital, Combined Residency Program in Emergency Medicine, Boston, MA, United States of America
| | - Christina Psaros
- Department of Psychiatry, Massachusetts General Hospital, Behavioral Medicine, Boston, MA, United States of America
| | - Abigail Harrison
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, RI, United States of America
| | - F. Nzwakie Mosery
- Department of Obstetrics and Gynaecology, MRU (MatCH), University of the Witwatersrand, Faculty of Health Sciences, Durban, South Africa
| | - Mxolisi Mathenjwa
- Department of Obstetrics and Gynaecology, MRU (MatCH), University of the Witwatersrand, Faculty of Health Sciences, Durban, South Africa
| | - Kasey O’Neil
- Center for Global Health and Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, United States of America
| | - Cecilia Milford
- Department of Obstetrics and Gynaecology, MRU (MatCH), University of the Witwatersrand, Faculty of Health Sciences, Durban, South Africa
| | - Steven A. Safren
- Department of Psychology, University of Miami, Coral Gables, FL, United States of America
| | - David R. Bangsberg
- Oregon Health & Science University-Portland State University School of Public Health, Portland, OR, United States of America
| | - Jennifer A. Smit
- Department of Obstetrics and Gynaecology, MRU (MatCH), University of the Witwatersrand, Faculty of Health Sciences, Durban, South Africa
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Onoya D, Hendrickson C, Sineke T, Maskew M, Long L, Bor J, Fox MP. Attrition in HIV care following HIV diagnosis: a comparison of the pre-UTT and UTT eras in South Africa. J Int AIDS Soc 2021; 24:e25652. [PMID: 33605061 PMCID: PMC7893145 DOI: 10.1002/jia2.25652] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 09/07/2020] [Accepted: 11/17/2020] [Indexed: 11/06/2022] Open
Abstract
INTRODUCTION Policies for Universal Test & Treat (UTT) and same-day initiation (SDI) of antiretroviral therapy (ART) were instituted in South Africa in September 2016 and 2017 respectively. However, there is limited evidence on whether these changes have improved patient retention after HIV diagnosis. METHODS We enrolled three cohorts of newly diagnosed HIV-infected adults from two primary health clinics in Johannesburg from April to November 2015 (Pre-UTT, N = 144), May-September 2017 (UTT, N = 178) and October-December 2017 (SDI, N = 88). A baseline survey was administered immediately after HIV diagnosis after which follow-up using clinical records (paper charts, electronic health records and laboratory data) ensued for 12 months. The primary outcome was patient loss to follow-up (being >90 days late for the last scheduled appointment) at 12 months post-HIV diagnosis. We modelled attrition across HIV policy periods with Cox proportional hazard regression. RESULTS Overall, 410 of 580 screened HIV-positive patients were enrolled. Overall, attrition at 12 months was 30% lower in the UTT guideline period (38.2%) compared to pre-UTT (47.2%, aHR 0.7, 95% CI: 0.5 to 1.0). However, the total attrition was similar between the SDI (47.7%) and pre-UTT cohorts (aHR 1.0, 95% CI: 0.7 to 1.5). Older age at HIV diagnosis (aHR 0.5 for ≥40 vs. 25 to 29 years, 95% CI: 0.3 to 0.8) and being in a non-marital relationship (aHR 0.5 vs. being single, 95% CI: 0.3 to 0.8) protected against LTFU at 12 months, whereas LTFU rates increased with longer travel time to the diagnosing clinic (aHR 1.8 for ≥30 minutes vs. ≤15 minutes, 95% CI: 1.1 to 3.1). In analyses adjusted for the time-varying ART initiation status, compared to the pre-ART period of care, the hazard of on-ART LTFU was 90% higher among participants diagnosed under the SDI policy compared to pre-UTT (aHR 1.9, 95% CI: 1.1 to 2.9). CONCLUSIONS Overall, nearly two-fifths of HIV positive patients are likely to disengage from care by 12 months after HIV diagnosis under the new SDI policy. Furthermore, the increase in on-ART patient attrition after the introduction of the SDI policy is cause for concern. Further research is needed to determine the best way for rapidly initiating patients on ART and also reducing long-term attrition from care.
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Affiliation(s)
- Dorina Onoya
- Health Economics and Epidemiology Research OfficeDepartment of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Cheryl Hendrickson
- Health Economics and Epidemiology Research OfficeDepartment of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Tembeka Sineke
- Health Economics and Epidemiology Research OfficeDepartment of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Mhairi Maskew
- Health Economics and Epidemiology Research OfficeDepartment of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Lawrence Long
- Health Economics and Epidemiology Research OfficeDepartment of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
- Department of Global HealthBoston University School of Public HealthBostonMAUSA
| | - Jacob Bor
- Health Economics and Epidemiology Research OfficeDepartment of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
- Department of Global HealthBoston University School of Public HealthBostonMAUSA
| | - Matthew P. Fox
- Health Economics and Epidemiology Research OfficeDepartment of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
- Department of Global HealthBoston University School of Public HealthBostonMAUSA
- Department of EpidemiologyBoston University School of Public HealthBostonMAUSA
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23
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Chauke P, Huma M, Madiba S. Lost to follow up rate in the first year of ART in adults initiated in a universal test and treat programme: a retrospective cohort study in Ekurhuleni District, South Africa. Pan Afr Med J 2020; 37:198. [PMID: 33505567 PMCID: PMC7813655 DOI: 10.11604/pamj.2020.37.198.25294] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Accepted: 09/26/2020] [Indexed: 12/03/2022] Open
Abstract
Introduction South Africa adopted and implemented the Universal Test and Treat (UTT) strategy for HIV since 2016. However, the care outcomes for patients initiated antiretroviral therapy (ART) through the UTT strategy have not been established. We determined the rate of lost to follow up (LTFU) and associated factors in patients who were initiated on ART through the UTT and the pre-ART strategy at 12 months post ART initiation. Methods this retrospective study analyzed the records of a cohort of patients at 12 months post the initiation of ART. We extracted data from the TIER.Net electronic database of selected facilities in a sub-district in Gauteng Province, South Africa. Factors associated with LFTU at 12 months of ART were assessed and logistic regression performed to identify predictors of LFTU. Results records of 367 patients were evaluated, and 54% were initiated ART through the UTT strategy. The mean age was 36.3 years, mean CD4 cell count at ART initiation was 341 cells/mm3, and 25% were initiated at CD4 cell count above 500 cells/mm3. LTFU at 12 months was 28%, 50% were LFTU within six months, and 28% within three months of ART. LFTU in the UTT cohort was higher than in the pre-ART cohort, patients initiated through UTT were twice more likely to be LTFU (AOR = 1.84, CI: 1.13-3.00) than pre-ART patients. Conclusion the rate of LTFU at 12 months of ART was 28%, which indicate that the retention in care rate (60%) falls far short of the triple 90 targets required for viral suppression.
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Affiliation(s)
- Patricia Chauke
- Department of Public Health, School of Health Care Sciences, Sefako Makgatho Health Sciences University, Pretoria, South Africa
| | - Mmampedi Huma
- Department of Public Health, School of Health Care Sciences, Sefako Makgatho Health Sciences University, Pretoria, South Africa
| | - Sphiwe Madiba
- Department of Public Health, School of Health Care Sciences, Sefako Makgatho Health Sciences University, Pretoria, South Africa
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Brault MA, Spiegelman D, Abdool Karim SS, Vermund SH. Integrating and Interpreting Findings from the Latest Treatment as Prevention Trials. Curr HIV/AIDS Rep 2020; 17:249-258. [PMID: 32297219 DOI: 10.1007/s11904-020-00492-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
PURPOSE OF REVIEW In 2018-2019, studies were published assessing the effectiveness of reducing HIV incidence by expanding HIV testing, linkage to HIV treatment, and assistance to persons living with HIV to adhere to their medications (the "90-90-90" strategy). These tests of "treatment as prevention" (TasP) had complex results. RECENT FINDINGS The TasP/ANRS 12249 study in South Africa, the SEARCH study in Kenya and Uganda, and one comparison (arms A to C) of the HPTN 071 (PopART) study in South Africa and Zambia did not demonstrate a community impact on HIV incidence. In contrast, the Botswana Ya Tsie study and the second comparison (arms B to C) of PopART indicated significant ≈ 30% reductions in HIV incidence in the intervention communities where TasP was expanded. We discuss the results of these trials and outline future research and challenges. These include the efficient expansion of widespread HIV testing, better linkage to care, and viral suppression among all persons living with HIV. A top implementation science priority for the next decade is to determine what strategies to use in specific local contexts.
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Affiliation(s)
- Marie A Brault
- Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, CT, USA.
| | - Donna Spiegelman
- Department of Biostatistics; Center for Methods in Implementation and Prevention Sciences, Yale School of Public Health, New Haven, CT, USA
| | - Salim S Abdool Karim
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Sten H Vermund
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
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Grimsrud A, Wilkinson L, Eshun-Wilson I, Holmes C, Sikazwe I, Katz IT. Understanding Engagement in HIV Programmes: How Health Services Can Adapt to Ensure No One Is Left Behind. Curr HIV/AIDS Rep 2020; 17:458-466. [PMID: 32844274 PMCID: PMC7497373 DOI: 10.1007/s11904-020-00522-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
PURPOSE OF REVIEW Despite the significant progress in the HIV response, gaps remain in ensuring engagement in care to support life-long medication adherence and viral suppression. This review sought to describe the different points in the HIV care cascade where people living with HIV were not engaging and highlight promising interventions. RECENT FINDINGS There are opportunities to improve engagement both between testing and treatment and to support re-engagement in care for those in a treatment interruption. The gap between testing and treatment includes people who know their HIV status and people who do not know their status. People in a treatment interruption include those who interrupt immediately following initiation, early on in their treatment (first 6 months) and late (after 6 months or more on ART). For each of these groups, specific interventions are required to support improved engagement. There are diverse needs and specific populations of people living with HIV who are not engaged in care, and differentiated service delivery interventions are required to meet their needs and expectations. For the HIV response to realise the 2030 targets, engagement will need to be supported by quality care and patient choice combined with empowered patients who are treatment literate and have been supported to improve self-management.
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Affiliation(s)
- Anna Grimsrud
- International AIDS Society, 3 Doris Road, Claremont, Cape Town, 7708 South Africa
- Desmond Tutu HIV Centre, University of Cape Town, Anzio Road, Observatory, Cape Town, 7925 South Africa
| | - Lynne Wilkinson
- International AIDS Society, 3 Doris Road, Claremont, Cape Town, 7708 South Africa
- Department of Public Health Medicine, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Charles Holmes
- Center for Innovation in Global Health, Georgetown University, Washington, DC USA
| | - Izukanji Sikazwe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Ingrid T. Katz
- Department of Medicine, Brigham and Women’s Hospital, Boston, MA USA
- Harvard Medical School, Boston, MA USA
- Massachusetts General Hospital Center for Global Health, Boston, MA USA
- Harvard Global Health Institute, Cambridge, MA USA
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Abebe Moges N, Olubukola A, Micheal O, Berhane Y. HIV patients retention and attrition in care and their determinants in Ethiopia: a systematic review and meta-analysis. BMC Infect Dis 2020; 20:439. [PMID: 32571232 PMCID: PMC7310275 DOI: 10.1186/s12879-020-05168-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Accepted: 06/17/2020] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND There is paucity of evidence on the magnitude of HIV patients' retention and attrition in Ethiopia. Hence, the aim of this study was to determine the pooled magnitude of HIV patient clinical retention and attrition and to identify factors associated with retention and attrition in Ethiopia. METHODS Systematic review and meta-analysis were done among studies conducted in Ethiopia using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. Both published and unpublished studies conducted from January 1, 2005 to June 6th, 2019 were included. Major databases and search engines such as Google Scholar, PUBMED, African Journals Online (AJOL) and unpublished sources were searched to retrieve relevant articles. Data were assessed for quality, heterogeneity and publication bias. Analysis was conducted using STATA version 14 software. RESULT From a total of 45 studies 546,250 study participants were included in this review. The pooled magnitude of retention in care among HIV patients was 70.65% (95% CI, 68.19, 73.11). The overall magnitude of loss to follow up 15.17% (95% CI, 11.86, 18.47), transfer out 11.17% (95% CI, 7.12, 15.21) and death rate were 6.75% (95% CI, 6.22, 7.27). Major determinants of attrition were being unmarried patient (OR 1.52, 95% CI: 1.15-2.01), non-disclosed HIV status (OR 6.36, 95% CI: 3.58-11.29), poor drug adherence (OR 6.60, 95% CI: 1.41-30.97), poor functional status (OR 2.11, 95% CI: 1.33-3.34), being underweight (OR 2.21, 95% CI: 1.45-3.39) and advanced clinical stage (OR 1.85, 95% CI: 1.36-2.51). Whereas absence of opportunistic infections (OR 0.52, 95% CI: 0.30-0.9), normal hemoglobin status (OR 0.29, 95% CI: 0.20-0.42) and non-substance use (OR 95% CI: 0.41, 0.17-0.98) were facilitators of HIV patient retention in clinical care. CONCLUSION The level of retention to the care among HIV patients was low in Ethiopia. Socio-economic, clinical, nutritional and behavioral, intervention is necessary to achieve adequate patient retention in clinical care.
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Affiliation(s)
- Nurilign Abebe Moges
- Department of Public Health, College of Health Sciences, Debre Markos University, Debre Markos, Ethiopia
- Pan African University, Life and Earth Sciences Including Health and Agriculture Institute (PAULESI), University of Ibadan, Ibadan, Nigeria
| | - Adesina Olubukola
- Department of Obstetrics and Gynecology, University College Hospital, University of Ibadan, Ibadan, Nigeria
| | - Okunlola Micheal
- Department of Obstetrics and Gynecology, University College Hospital, University of Ibadan, Ibadan, Nigeria
| | - Yemane Berhane
- Department of Epidemiology, Addis Continental Institute of Public Health, Addis Ababa, Ethiopia
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Matare T, Shewade HD, Ncube RT, Masunda K, Mukeredzi I, Takarinda KC, Dzangare J, Gonese G, Khabo BB, Choto RC, Apollo T. Anti-retroviral therapy after "Treat All" in Harare, Zimbabwe: What are the changes in uptake, time to initiation and retention? F1000Res 2020; 9:287. [PMID: 32934801 PMCID: PMC7475956 DOI: 10.12688/f1000research.23417.2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/29/2020] [Indexed: 11/20/2022] Open
Abstract
Background: In Zimbabwe, Harare was the first province to implement "Treat All" for people living with human immunodeficiency virus (PLHIV). Since its roll out in July 2016, no study has been conducted to assess the changes in key programme indicators. We compared antiretroviral therapy (ART) uptake, time to ART initiation from diagnosis, and retention before and during "Treat All". Methods: We conducted an ecological study to assess ART uptake among all PLHIV newly diagnosed before and during "Treat All". We conducted a cohort study to assess time to ART initiation and retention in care among all PLHIV newly initiated on ART from all electronic patient management system-supported sites (n=50) before and during "Treat All". Results: ART uptake increased from 65% (n=4619) by the end of quarter one, 2014 to 85% (n=5152) by the end of quarter four, 2018. A cohort of 2289 PLHIV was newly initiated on ART before (April-June 2015) and 1682 during "Treat all" (April-June 2017). Their age and gender distribution was similar. The proportion of PLHIV in early stages of disease was significantly higher during "Treat all" (73.2% vs. 55.6%, p<0.001). The median time to ART initiation was significantly lower during "Treat All" (31 vs. 88 days, p<0.001). Cumulative retention at three, six and 12 months was consistently lower during "Treat all" and was significant at six months (74.9% vs.78.1% p=0.022). Conclusion: Although there were benefits of early ART initiation during "Treat All", the programme should consider strategies to improve retention.
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Affiliation(s)
- Takura Matare
- AIDS and TB Unit, Ministry of Health and Child Care, Harare, Zimbabwe
| | - Hemant Deepak Shewade
- The Union South-East Asia Office, New Delhi, India.,International Union Against Tuberculosis and Lung Disease (The Union), Paris, France
| | | | | | | | - Kudakwashe C Takarinda
- AIDS and TB Unit, Ministry of Health and Child Care, Harare, Zimbabwe.,International Union Against Tuberculosis and Lung Disease (The Union), Paris, France
| | - Janet Dzangare
- AIDS and TB Unit, Ministry of Health and Child Care, Harare, Zimbabwe
| | - Gloria Gonese
- International Training and Education Centre for Health (I-TECH), Harare, Zimbabwe
| | - Bekezela B Khabo
- AIDS and TB Unit, Ministry of Health and Child Care, Harare, Zimbabwe
| | - Regis C Choto
- AIDS and TB Unit, Ministry of Health and Child Care, Harare, Zimbabwe
| | - Tsitsi Apollo
- AIDS and TB Unit, Ministry of Health and Child Care, Harare, Zimbabwe
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Matare T, Shewade HD, Ncube RT, Masunda K, Mukeredzi I, Takarinda KC, Dzangare J, Gonese G, Khabo BB, Choto RC, Apollo T. Anti-retroviral therapy after "Treat All" in Harare, Zimbabwe: What are the changes in uptake, time to initiation and retention? F1000Res 2020; 9:287. [PMID: 32934801 PMCID: PMC7475956 DOI: 10.12688/f1000research.23417.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/29/2020] [Indexed: 08/31/2023] Open
Abstract
Background: In Zimbabwe, Harare was the first province to implement "Treat All" for people living with human immunodeficiency virus (PLHIV). Since its roll out in July 2016, no study has been conducted to assess the changes in key programme indicators. We compared antiretroviral therapy (ART) uptake, time to ART initiation from diagnosis, and retention before and during "Treat All". Methods: We conducted an ecological study to assess ART uptake among all PLHIV newly diagnosed before and during "Treat All". We conducted a cohort study to assess time to ART initiation and retention in care among all PLHIV newly initiated on ART from all electronic patient management system-supported sites (n=50) before and during "Treat All". Results: ART uptake increased from 65% (n=4619) by the end of quarter one, 2014 to 85% (n=5152) by the end of quarter four, 2018. A cohort of 2289 PLHIV was newly initiated on ART before (April-June 2015) and 1682 during "Treat all" (April-June 2017). Their age and gender distribution was similar. The proportion of PLHIV in early stages of disease was significantly higher during "Treat all" (73.2% vs. 55.6%, p<0.001). The median time to ART initiation was significantly lower during "Treat All" (31 vs. 88 days, p<0.001). Cumulative retention at three, six and 12 months was consistently lower during "Treat all" and was significant at six months (74.9% vs.78.1% p=0.022). Conclusion: Although there were benefits of early ART initiation during "Treat All", the programme should consider strategies to improve retention.
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Affiliation(s)
- Takura Matare
- AIDS and TB Unit, Ministry of Health and Child Care, Harare, Zimbabwe
| | - Hemant Deepak Shewade
- The Union South-East Asia Office, New Delhi, India
- International Union Against Tuberculosis and Lung Disease (The Union), Paris, France
| | | | | | | | - Kudakwashe C. Takarinda
- AIDS and TB Unit, Ministry of Health and Child Care, Harare, Zimbabwe
- International Union Against Tuberculosis and Lung Disease (The Union), Paris, France
| | - Janet Dzangare
- AIDS and TB Unit, Ministry of Health and Child Care, Harare, Zimbabwe
| | - Gloria Gonese
- International Training and Education Centre for Health (I-TECH), Harare, Zimbabwe
| | - Bekezela B. Khabo
- AIDS and TB Unit, Ministry of Health and Child Care, Harare, Zimbabwe
| | - Regis C. Choto
- AIDS and TB Unit, Ministry of Health and Child Care, Harare, Zimbabwe
| | - Tsitsi Apollo
- AIDS and TB Unit, Ministry of Health and Child Care, Harare, Zimbabwe
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Kerschberger B, Schomaker M, Jobanputra K, Kabore SM, Teck R, Mabhena E, Mthethwa‐Hleza S, Rusch B, Ciglenecki I, Boulle A. HIV programmatic outcomes following implementation of the 'Treat-All' policy in a public sector setting in Eswatini: a prospective cohort study. J Int AIDS Soc 2020; 23:e25458. [PMID: 32128964 PMCID: PMC7054447 DOI: 10.1002/jia2.25458] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 12/04/2019] [Accepted: 01/22/2020] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION The Treat-All policy - antiretroviral therapy (ART) initiation irrespective of CD4 cell criteria - increases access to treatment. Many ART programmes, however, reported increasing attrition and viral failure during treatment expansion, questioning the programmatic feasibility of Treat-All in resource-limited settings. We aimed to describe and compare programmatic outcomes between Treat-All and standard of care (SOC) in the public sectors of Eswatini. METHODS This is a prospective cohort study of ≥16-year-old HIV-positive patients initiated on first-line ART under Treat-All and SOC in 18 health facilities of the Shiselweni region, from October 2014 to March 2016. SOC followed the CD4 350 and 500 cells/mm3 treatment eligibility thresholds. Kaplan-Meier estimates were used to describe crude programmatic outcomes. Multivariate flexible parametric survival models were built to assess associations of time from ART initiation with the composite unfavourable outcome of all-cause attrition and viral failure. RESULTS Of the 3170 patients, 1888 (59.6%) initiated ART under Treat-All at a median CD4 cell count of 329 (IQR 168 to 488) cells/mm3 compared with 292 (IQR 161 to 430) (p < 0.001) under SOC. Although crude programme retention at 36 months tended to be lower under Treat-All (71%) than SOC (75%) (p = 0.002), it was similar in covariate-adjusted analysis (adjusted hazard ratio [aHR] 1.06, 95% CI 0.91 to 1.23). The hazard of viral suppression was higher for Treat-All (aHR 1.12, 95% CI 1.01 to 1.23), while the hazard of viral failure was comparable (Treat-All: aHR 0.89, 95% CI 0.53 to 1.49). Among patients with advanced HIV disease (n = 1080), those under Treat-All (aHR 1.13, 95% CI 0.88 to 1.44) had a similar risk of an composite unfavourable outcome to SOC. Factors increasing the risk of the composite unfavourable outcome under both interventions were aged 16 to 24 years, being unmarried, anaemia, ART initiation on the same day as HIV care enrolment and CD4 ≤ 100 cells/mm3 . Under Treat-All only, the risk of the unfavourable outcome was higher for pregnant women, WHO III/IV clinical stage and elevated creatinine. CONCLUSIONS Compared to SOC, Treat-All resulted in comparable retention, improved viral suppression and comparable composite outcomes of retention without viral failure.
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Affiliation(s)
- Bernhard Kerschberger
- Médecins Sans Frontières (Operational Centre Geneva)MbabaneEswatini
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
| | - Michael Schomaker
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
- Institute of Public Health, Medical Decision Making and Health Technology AssessmentUMIT ‐ University for Health Sciences, Medical Informatics and TechnologyHall in TirolAustria
| | | | - Serge M Kabore
- Médecins Sans Frontières (Operational Centre Geneva)MbabaneEswatini
| | - Roger Teck
- The Manson UnitMédecins Sans FrontièresLondonUnited Kingdom
| | - Edwin Mabhena
- Médecins Sans Frontières (Operational Centre Geneva)MbabaneEswatini
| | | | - Barbara Rusch
- Médecins Sans Frontières (Operational Centre Geneva)GenevaSwitzerland
| | - Iza Ciglenecki
- Médecins Sans Frontières (Operational Centre Geneva)GenevaSwitzerland
| | - Andrew Boulle
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
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Larmarange J, Diallo MH, McGrath N, Iwuji C, Plazy M, Thiébaut R, Tanser F, Bärnighausen T, Orne‐Gliemann J, Pillay D, Dabis F. Temporal trends of population viral suppression in the context of Universal Test and Treat: the ANRS 12249 TasP trial in rural South Africa. J Int AIDS Soc 2019; 22:e25402. [PMID: 31637821 PMCID: PMC6803817 DOI: 10.1002/jia2.25402] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 09/03/2019] [Indexed: 01/09/2023] Open
Abstract
INTRODUCTION The universal test-and-treat (UTT) strategy aims to maximize population viral suppression (PVS), that is, the proportion of all people living with HIV (PLHIV) on antiretroviral treatment (ART) and virally suppressed, with the goal of reducing HIV transmission at the population level. This article explores the extent to which temporal changes in PVS explain the observed lack of association between universal treatment and cumulative HIV incidence seen in the ANRS 12249 TasP trial conducted in rural South Africa. METHODS The TasP cluster-randomized trial (2012 to 2016) implemented six-monthly repeat home-based HIV counselling and testing (RHBCT) and referral of PLHIV to local HIV clinics in 2 × 11 clusters opened sequentially. ART was initiated according to national guidelines in control clusters and regardless of CD4 count in intervention clusters. We measured residency status, HIV status, and HIV care status for each participant on a daily basis. PVS was computed per cluster among all resident PLHIV (≥16, including those not in care) at cluster opening and daily thereafter. We used a mixed linear model to explore time patterns in PVS, adjusting for sociodemographic changes at the cluster level. RESULTS 8563 PLHIV were followed. During the course of the trial, PVS increased significantly in both arms (23.5% to 46.2% in intervention, +22.8, p < 0.001; 26.0% to 44.6% in control, +18.6, p < 0.001). That increase was similar in both arms (p = 0.514). In the final adjusted model, PVS increase was most associated with increased RHBCT and the implementation of local trial clinics (measured by time since cluster opening). Contextual changes (measured by calendar time) also contributed slightly. The effect of universal ART (trial arm) was positive but limited. CONCLUSIONS PVS was improved significantly but similarly in both trial arms, explaining partly the null effect observed in terms of cumulative HIV incidence between arms. The PVS gains due to changes in ART-initiation guidelines alone are relatively small compared to gains obtained by strategies to maximize testing and linkage to care. The achievement of the 90-90-90 targets will not be met if the operational and implementational challenges limiting access to care and treatment, often context-specific, are not properly addressed. Clinical trial number: NCT01509508 (clinicalTrials.gov)/DOH-27-0512-3974 (South African National Clinical Trials Register).
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Affiliation(s)
- Joseph Larmarange
- Centre Population et DéveloppementInstitut de Recherche pour le DéveloppementUniversité Paris DescartesInsermParisFrance
- Africa Health Research InstituteKwaZulu‐NatalSouth Africa
| | - Mamadou H Diallo
- Centre Population et DéveloppementInstitut de Recherche pour le DéveloppementUniversité Paris DescartesInsermParisFrance
| | - Nuala McGrath
- Africa Health Research InstituteSchool of Nursing and Public HealthUniversity of KwaZulu‐NatalKwaZulu‐NatalSouth Africa
- Faculty of Medicine and Faculty of Social SciencesUniversity of SouthamptonSouthamptonUnited Kingdom
- Research Department of Infection and Population HealthUniversity College LondonLondonUnited Kingdom
| | - Collins Iwuji
- Africa Health Research InstituteKwaZulu‐NatalSouth Africa
- Research Department of Infection and Population HealthUniversity College LondonLondonUnited Kingdom
- Department of Global Health & InfectionBrighton and Sussex Medical SchoolBrightonUnited Kingdom
| | - Mélanie Plazy
- School of Public Health (ISPED)InsermBordeaux Population Health Research CenterUMR 1219Bordeaux UniversityBordeauxFrance
| | - Rodolphe Thiébaut
- School of Public Health (ISPED)InsermBordeaux Population Health Research CenterUMR 1219Bordeaux UniversityBordeauxFrance
| | - Frank Tanser
- Africa Health Research InstituteSchool of Nursing and Public HealthUniversity of KwaZulu‐NatalKwaZulu‐NatalSouth Africa
| | - Till Bärnighausen
- Africa Health Research InstituteKwaZulu‐NatalSouth Africa
- Department of Global Health & PopulationHarvard School of Public HealthHarvard UniversityBostonUSA
- Faculty of MedicineInstitute of Public HealthHeidelberg UniversityHeidelbergGermany
| | - Joanna Orne‐Gliemann
- School of Public Health (ISPED)InsermBordeaux Population Health Research CenterUMR 1219Bordeaux UniversityBordeauxFrance
| | - Deenan Pillay
- Africa Health Research InstituteKwaZulu‐NatalSouth Africa
- Division of Infection and ImmunityUniversity College LondonLondonUnited Kingdom
| | - François Dabis
- School of Public Health (ISPED)InsermBordeaux Population Health Research CenterUMR 1219Bordeaux UniversityBordeauxFrance
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