'You Have to Withstand That Because You Have Come for What You Have Come for': Barriers and facilitators to antiretroviral treatment access among older South Africans living with HIV

"I am still human and worth a life:" a qualitative study of the impacts of a community based, peer-led, treatment support model for young adults living with HIV in Zimbabwe

Background

A persistent treatment gap remains between children and adults living with HIV. The Zvandiri program, developed by Africaid, is one of the few models of differentiated service delivery for children, adolescents, and youth that has been shown to improve outcomes along the HIV care continuum, employing Community Adolescent Treatment Supporters (CATS) to offer peer counseling and patient navigation. Our qualitative study provides an in-depth analysis of the feelings and experiences Zimbabwean youth had following an HIV diagnosis, and the ways that CATS facilitated linkage and retention in care.

Methods

We conducted in-depth interviews in Shona with adolescents and young adults who were recently diagnosed with HIV in Zimbabwe. Interviews were audio-recorded, transcribed, and then translated to English. Interviews were coded in Dedoose using a structured a priori codebook. We wrote semi-structured summary memos for each interview. We co-conducted thematic analysis, guided by interpretive phenomenology with a team of Zimbabwean and American experienced qualitative researchers and community partners. We co-developed memos to elaborate and understand key themes across interviews.

Results

Most of our interview participants recounted an immediate sense of loss upon testing HIV positive and a fear that "there was no hope for the future." CATS played a pivotal role for youth, providing emotional, educational, and logistical support to facilitate treatment initiation, adherence, and persistence in care. The CATS program supported youth through multiple approaches: group sessions, individual meetings, and via text or phone. While CATS offered counseling and comfort to participants, they emphasized the long-term importance of identifying at least one other person in participants' lives who could know their status and support them around HIV.

Conclusion

Our findings delineate some of the key concerns that face youth after receiving an HIV diagnosis and the ways that a community-based adherence peer navigation program supported participants to navigate both their feelings and the health care system. Results can inform practice at community-based agencies that are implementing or considering peer youth navigation programs and garner support for policy to fund interventions for youth.

"I only seek treatment when I am ill": experiences of hypertension and diabetes care among adults living with HIV in urban Tanzania

BACKGROUND

For adults living with HIV (ALHIV) and comorbidities, access to comprehensive healthcare services is crucial to achieving optimal health outcomes. This study aims to describe lived experiences, challenges, and coping strategies for accessing care for hypertension and/or diabetes (HTN/DM) in HIV care and treatment clinics (CTCs) and other healthcare settings.

METHODOLOGY

We conducted a qualitative study that employed a phenomenological approach between January and April 2022 using a semi-structured interview guide in six HIV CTCs in Dar es Salaam, Tanzania. We purposively recruited 33 ALHIV with HTN (n = 16), DM (n = 10), and both (n = 7). Thematic content analysis was guided by the 5As framework of access to care.

FINDINGS

The majority of the participants were females, between the ages of 54-73, and were recruited from regional referral hospitals. HIV CTCs at regional referral hospitals had more consistent provision of HTN screening services compared to those from district hospitals and health centers. Participants sought HTN/DM care at non-CTC health facilities due to the limited availability of such services at HIV CTCs. However, healthcare delivery for these conditions was perceived as unaccommodating and poorly coordinated. The need to attend multiple clinic appointments for the management of HTN/DM in addition to HIV care was perceived as frustrating, time-consuming, and financially burdensome. High costs of care and transportation, limited understanding of comorbidities, and the perceived complexity of HTN/DM care contributed to HTN/DM treatment discontinuity. As a means of coping, participants frequently monitored their own HTN/DM symptoms at home and utilized community pharmacies and dispensaries near their residences to check blood pressure and sugar levels and obtain medications. Participants expressed a preference for non-pharmaceutical approaches to comorbidity management such as lifestyle modification (preferred by young participants) and herbal therapies (preferred by older participants) because of concerns about side effects and perceived ineffectiveness of HTN/DM medications. Participants also preferred integrated care and focused patient education on multimorbidity management at HIV CTCs.

CONCLUSION

Our findings highlight significant barriers to accessing HTN/DM care among ALHIV, mostly related to affordability, availability, and accessibility. Integration of NCD care into HIV CTCs, could greatly improve ALHIV health access and outcomes and align with patient preference.

Promoting Resilience among Middle-Aged and Older Men Who Have Sex with Men Living with HIV/AIDS in Southern Nevada: An Examination of Facilitators and Challenges from a Social Determinants of Health Perspective

Most prior research on resilience to HIV/AIDS among middle-aged and older men who have sex with men (MSM) has utilized quantitative methods that employ surveys and scales to measure constructs researchers have used to approximate the concept of resilience to HIV/AIDS. Only a few studies have purposively made efforts to incorporate the input of relevant stakeholders to guide their research on HIV/AIDS resilience and examine the perspectives and lived experiences of middle-aged and older MSM. To address this research gap, we conducted a community-based participatory research qualitative study to examine the perspectives and lived experiences of HIV-positive, middle-aged and older MSM from Southern Nevada in order to identify factors that promote such resilience. We conducted 16 semi-structured interviews with middle-aged and older MSM living with HIV/AIDS from January to April 2022. From our thematic analysis of our interviews, we identified factors that served as facilitators or challenges to the promotion of our participants' HIV/AIDS resilience. We discuss in this article both the facilitators and challenges to our participants' resilience-building as the key themes from our interviews. We recognized that the impacts of these factors were mediated by their strong influence on the social determinants of health that were explicitly relevant to our participants. We offer important insights based on our findings, which could be especially useful to future research on resilience to HIV/AIDS.

A Focus on Aging, HIV/AIDS, and Neurocognitive Challenges: Examining Southern Nevada HIV Sector Providers' Awareness and Prospective Roles

Although abundant research has been carried out to investigate the underlying mechanisms that may cause neurocognitive challenges among middle-aged and older people living with HIV/AIDS (PLWH), to monitor the prevalence rates of HIV-related neurocognitive deficits, and to identify factors related to the improvement of diagnostic screening tools, classification and nosology, and clinical and rehabilitative treatment of HIV-Associated Neurocognitive Disorder (HAND); to date, there have been only a few studies that have explored and examined the awareness and work experiences HIV sector healthcare and service providers have related to HAND. To address this research gap, we conducted a qualitative, community-based participatory research study and interviewed 12 HIV sector providers in Southern Nevada, USA, from January to April 2022. After performing a thematic analysis of our interviews, we were able to identify two major themes and several sub-themes. Under our first major theme, provider awareness and knowledge, we identified four sub-themes: (1) prior knowledge and current awareness; (2) lived experiences of patients and clients with neurocognitive challenges; (3) lack of knowledge as a barrier to providing needed care; and (4) continuing education and professional development. Under our second major theme, prospective provider roles, we identified three sub-themes: (1) early detection; (2) direct and practical support; and (3) appropriate and timely referrals. In this article, we discuss our findings and lessons learned from our study, as well as their implications for the future work of researchers and providers in the HIV sector related to improving care and support for people aging with HIV/AIDS and experiencing neurocognitive challenges.

Navigating Life With HIV as an Older Adult on the Kenyan Coast: Perceived Health Challenges Seen Through the Biopsychosocial Model

Objectives: This study explores the perceptions of adults living with HIV aged ≥50 years (recognized as older adults living with HIV-OALWH), primary caregivers and healthcare providers on the health challenges of ageing with HIV at Kilifi, a low literacy setting on the coast of Kenya. Methods: We utilized the biopsychosocial model to explore views from 34 OALWH and 22 stakeholders on the physical, mental, and psychosocial health challenges of ageing with HIV in Kilifi in 2019. Data were drawn from semi-structured in-depth interviews, which were audio-recorded and transcribed. A framework approach was used to synthesize the data. Results: Symptoms of common mental disorders, comorbidities, somatic symptoms, financial difficulties, stigma, and discrimination were viewed as common. There was also an overlap of perceived risk factors across the physical, mental, and psychosocial health domains, including family conflicts and poverty. Conclusion: OALWH at the Kenyan coast are perceived to be at risk of multiple physical, mental, and psychosocial challenges. Future research should quantify the burden of these challenges and examine the resources available to these adults.

How Midwestern College students protected their families in the first year of COVID-19

Introduction

College students routinely visit their families due to geographic proximity and their financial dependence. Consequently, the potential of transmitting COVID-19 from campus to their families' homes is consequential. Family members are key sources of support for one another in nearly all matters but there is little research uncovering the mechanisms by which families have protected each other in the pandemic.

Methods

Through an exploratory qualitative study, we examined the perspectives of a diverse, randomly sampled, group of students from a Midwestern University (pseudonym), in a college town, to identify COVID-19 prevention practices with their family members. We interviewed 33 students between the end of December 2020 and mid-April 2021 and conducted a thematic analysis through an iterative process.

Results

Students navigated major differences in opinions and undertook significant actions in attempts to protect their family members from COVID-19 exposure. Students' actions were rooted in the greater good of public health; prosocial behavior was on display.

Discussion

Larger public health initiatives could target the broader population by involving students as messengers.

"I'm Getting Life from the Treatment": Perceptions of Life and Death Among Middle-Aged and Older Medication-Adherent Persons Living with HIV in Rural South Africa

The widespread availability of health information and treatment for HIV in Southern Africa does not reach all populations. Few programs and materials are developed with middle-aged and older rural individuals living with HIV as the target audience, despite this being a growing population. This vacuum inevitably exacerbates the disjuncture between clinical and experiential knowledge. This study uses in-depth interviews from 2018 with middle-aged and older rural South Africans who self-report medication adherence to ART in order to explore experiences of living with HIV and beliefs about anti-retroviral treatment (ART). Participants revealed a general sense of vulnerability as a major motivation for HIV medication adherence. A majority of the participants believed that death was imminent if they defaulted on ART at any point in time. Although the availability of ART brought hope to many, HIV was still perceived as a death sentence, particularly if ART adherence was imperfect. The study findings suggest a need to examine the psychosocial component of community programs for middle-aged and older people living with HIV. For this growing population that experienced the full course of the epidemic, more research is needed on the burden of psychological and mental health issues emerging from the need for long-term HIV medication adherence.

Ageing with HIV: Medicine Optimisation Challenges and Support Needs for Older People Living with HIV: A Systematic Review

BACKGROUND

Older people living with HIV (PLWH) are at increased risks of co-morbidities and polypharmacy. However, little is known about factors affecting their needs and concerns about medicines. This systematic review aims to describe these and to identify interventions to improve medicine optimisation outcomes in older PLWH.

METHODS AND DATA SOURCES

Multiple databases and grey literature were searched from inception to February 2022 including MEDLINE, CINAHL, PsycInfo, PsychArticles, the Cochrane Database of Systematic Reviews and the Cochrane Controlled Register of Trials, Abstracts in Social Gerontology, and Academic Search Complete.

ELIGIBILITY CRITERIA

Studies reporting interventions/issues affecting older PLWH (sample populations with mean/median age ≥ 50 years; any aspect of medicine optimisation, or concerns). Quality assessments were completed by means of critical appraisal checklists for each study design. Title and abstract screening was led by one reviewer and a sample reviewed independently by two reviewers. Full-paper reviews were completed by one author and a 20% sample was reviewed independently by two reviewers.

SYNTHESIS

Data were extracted by three independent reviewers using standardised data extraction forms and synthesised according to outcomes or interventions reported. Data were summarised to include key themes, outcomes or concerns, and summary of intervention.

RESULTS

Seventy-nine (n = 79) studies met the eligibility criteria, most of which originated from the USA (n = 36). A few studies originated from Australia (n = 5), Canada (n = 5), Spain (n = 9), and the UK (n = 5). Ten studies originated from Sub-Saharan Africa (Kenya n = 1, South Africa n = 6, Tanzania n = 1, Uganda n = 1, Zimbabwe n = 1). The rest of the studies were from China (n = 1), France (n = 1), Germany (n = 1), Italy (n = 1), the Netherlands (n = 1), Pakistan (n = 1), Switzerland (n = 1), Saudi Arabia (n = 1) and Ukraine (n = 1). Publication dates ranged from 2002 to 2022. Sample sizes ranged from 10 to 15,602 across studies. The factors affecting older PLWH's experience of and issues with medicines were co-morbidities, health-related quality of life, polypharmacy, drug interactions, adverse drug reactions, adherence, medicine burden, treatment burden, stigma, social support, and patient-healthcare provider relationships. Nine interventions were identified to target older persons, five aimed at improving medication adherence, two to reduce drug interactions, and two for medicine self-management initiatives.

CONCLUSION

Further in-depth research is needed to understand older PLWH's experiences of medicines and their priority issues. Adherence-focused interventions are predominant, but there is a scarcity of interventions aimed at improving medicine experiences for this population. Multi-faceted interventions are needed to achieve medicine optimisation outcomes for PLWH.

TRIAL REGISTRATION

This study is registered with PROSPERO registration number: CRD42020188448.

Social Support for Improved ART Adherence and Retention in Care among Older People Living with HIV in Urban South Africa: A Complex Balance between Disclosure and Stigma

The number of older people living with HIV (OPLWH) (aged 50-plus) in South Africa is increasing as people age with HIV or are newly infected. OPLWH are potentially vulnerable because of the intersection of age-related and HIV stigmas, co-morbidities, and lack of social support. Evidence from younger populations suggests that social support can improve ART adherence and retention in care. Further, HIV status disclosure plays a role in mediating social support and may reduce stigma by facilitating access to social support. This paper draws on qualitative research with OPLWH to explore the complex associations between disclosure, social support, and HIV stigma among OPLWH in urban Western Cape. The findings demonstrate that OPLWH receive most of their support from their family and this support can facilitate adherence to ART and retention in care. However, social support is facilitated by participants' disclosure, thus, when perceived stigma limits disclosure, social support is less accessible. Gender, age, and pre-existing vulnerability also affect disclosure to and support from kin and community. Given that social support, particularly from family members, amplifies HIV care access and ART adherence, encouraging disclosure stimulating household HIV competency is likely to both address anticipated stigma and support improved OPLWH's health outcomes.

Uptake of community‐ versus clinic‐based antiretroviral therapy dispensing in the Central Chronic Medication Dispensing and Distribution program in South Africa

Introduction

South Africa's government‐led Central Chronic Medication Dispensing and Distribution (CCMDD) program offers people living with HIV the option to collect antiretroviral therapy at their choice of community‐ or clinic‐based pick‐up points intended to increase convenience and decongest clinics. To understand CCMDD pick‐up point use among people living with HIV, we evaluated factors associated with uptake of a community‐ versus clinic‐based pick‐up point at CCMDD enrolment.

Methods

We collected baseline data from October 2018 to March 2020 on adults (≥18 years) who met CCMDD clinical eligibility criteria (non‐pregnant, on antiretroviral therapy for ≥1 year and virologically suppressed) as part of an observational cohort in seven public clinics in KwaZulu‐Natal. We identified factors associated with community‐based pick‐up point uptake and fit a multivariable logistic regression model, including age, gender, employment status, self‐perceived barriers to care, self‐efficacy, HIV‐related discrimination, and perceived benefits and challenges of CCMDD.

Results and Discussion

Among 1521 participants, 67% were females, with median age 36 years (IQR 30–44). Uptake of a community‐based pick‐up point was associated with younger age (aOR 1.18 per 10‐year decrease, 95% CI 1.05–1.33), being employed ≥40 hours per week (aOR 1.42, 95% CI 1.10–1.83) versus being unemployed, no self‐perceived barriers to care (aOR 1.42, 95% CI 1.09–1.86) and scoring between 36 and 39 (aOR 1.44, 95% CI 1.03–2.01) or 40 (aOR 1.91, 95% CI 1.39–2.63) versus 10–35 on the self‐efficacy scale, where higher scores indicate greater self‐efficacy. Additional factors included more convenient pick‐up point location (aOR 2.32, 95% CI 1.77–3.04) or hours (aOR 5.09, 95% CI 3.71–6.98) as perceived benefits of CCMDD, and lack of in‐clinic follow‐up after a missed collection date as a perceived challenge of CCMDD (aOR 4.37, 95% CI 2.30–8.31).

Conclusions

Uptake of community‐based pick‐up was associated with younger age, full‐time employment, and systemic and structural factors of living with HIV (no self‐perceived barriers to care and high self‐efficacy), as well as perceptions of CCMDD (convenient pick‐up point location and hours, lack of in‐clinic follow‐up). Strategies to facilitate community‐based pick‐up point uptake should be tailored to patients’ age, employment, self‐perceived barriers to care and self‐efficacy to maximize the impact of CCMDD in decongesting clinics.