Remembering individual perspectives and needs in differentiated HIV care strategies

Challenges and Opportunities in Big Data Science to Address Health Inequities and Focus the HIV Response

PURPOSE OF REVIEW

Big Data Science can be used to pragmatically guide the allocation of resources within the context of national HIV programs and inform priorities for intervention. In this review, we discuss the importance of grounding Big Data Science in the principles of equity and social justice to optimize the efficiency and effectiveness of the global HIV response.

RECENT FINDINGS

Social, ethical, and legal considerations of Big Data Science have been identified in the context of HIV research. However, efforts to mitigate these challenges have been limited. Consequences include disciplinary silos within the field of HIV, a lack of meaningful engagement and ownership with and by communities, and potential misinterpretation or misappropriation of analyses that could further exacerbate health inequities. Big Data Science can support the HIV response by helping to identify gaps in previously undiscovered or understudied pathways to HIV acquisition and onward transmission, including the consequences for health outcomes and associated comorbidities. However, in the absence of a guiding framework for equity, alongside meaningful collaboration with communities through balanced partnerships, a reliance on big data could continue to reinforce inequities within and across marginalized populations.

Opportunities and considerations for the design of decentralized delivery of antiretroviral therapy for female sex workers living with HIV in South Africa

Background

In South Africa, 60% of female sex workers (FSW) are living with HIV, many of whom experience structural and individual barriers to antiretroviral therapy (ART) initiation and adherence. Community-based decentralized treatment provision (DTP) may mitigate these barriers. To characterize optimal implementation strategies, we explored preferences for DTP among FSW living with HIV in Durban, South Africa.

Methods

Thirty-nine semi-structured in-depth interviews were conducted with FSW living with HIV (n = 24), and key informants (n = 15) including HIV program implementers, security personnel, and brothel managers. Participants were recruited using maximum variation and snowball sampling. Interviews were conducted in English or isiZulu between September–November 2017 and analyzed using grounded theory in Atlas.ti 8.

Results

DTP was described as an intervention that could address barriers to ART adherence and retention, minimizing transport costs, time and wage loss from clinic visits, and act as a safety net to address FSW mobility and clinic access challenges. Respondents highlighted contextual considerations for DTP and suggested that DTP should be venue-based, scheduled during less busy times and days, and integrate comprehensive health services including psychological, reproductive, and non-communicable disease services. ART packaging and storage were important for community-based delivery, and participants suggested DTP should be implemented by sex work sensitized staff with discrete uniform and vehicle branding.

Conclusions

Incorporating FSW preferences may support implementation optimization and requires balancing of tensions between preferences and feasibility. These data suggest the potential utility of DTP for FSW as a strategy to address those most marginalized from current ART programs in South Africa.

HIV Testing Approaches to Optimize Prevention and Treatment for Key and Priority Populations in Malawi

Background

Despite progress in improving antiretroviral therapy (ART) for people with HIV in Malawi, the burden of HIV infections and HIV treatment outcomes among key populations is suboptimal. Client-centered differentiated service delivery approaches may facilitate addressing HIV prevention and treatment needs of key populations in Malawi.

Methods

De-identified program data routinely collected as part of the LINKAGES project–Malawi were assembled from October 2017 to September 2019. HIV case finding was compared across different testing modalities for each population. Poisson regression was used to estimate the association between testing modalities and ART initiation.

Results

Of the 18 397 people included in analyses, 10627 (58%) were female sex workers (FSWs), 2219 (12%) were men who have sex with men (MSM), and 4970 (27%) were clients of FSWs. HIV case finding varied by modality and population, with index testing and enhanced peer outreach demonstrating high yield despite reaching relatively few individuals. FSWs who tested positive through risk network referral testing were more likely to initiate ART within 30 days compared with those who tested positive through clinic-based testing (adjusted risk ratio [aRR], 1.50; 95% CI, 1.23–1.82). For MSM, index testing (aRR, 1.45; 95% CI, 1.06–2.00) and testing through a drop-in center (aRR, 1.82; 95% CI, 1.19–2.78) were associated with 30-day ART initiation.

Conclusions

These data suggest that differentiated HIV testing and outreach approaches tailored to the needs of different key populations may facilitate improved ART initiation in Malawi. Achieving 0 new infections by 2030 suggests the need to adapt treatment strategies given individual and structural barriers to treatment for key populations with HIV in high-prevalence settings.

Access to chronic medicines: patients' preferences for a last kilometre medicine delivery service in Cape Town, South Africa

Background

Chronic patients are required to access their chronic medicines on a regular basis, often only to refill their repeat prescriptions. Adherence to chronic medicines is challenging and has stimulated health care providers to devise differentiated service delivery models of care to decentralise chronic medicine distribution to decrease the frequency of medicine collection at health care facilities. One such option includes a last kilometre medicine delivery service. This study investigated chronic patients’ preferences for a last kilometre medicine delivery service model.

Methods

An exploratory non-randomised quantitative study was conducted over 4 weeks at four public sector primary health care facilities in Cape Town, South Africa. Data was collected on a structured questionnaire from chronic patients queuing to receive medication at each facility’s pharmacy waiting area. Patient demographics were noted to align with preferences for chronic medicine service delivery characteristics including; mobile ordering, fee for service and location for delivery. Chi-square test and frequencies were employed to analyse data using SPSS version 23.

Results

A total of 116 patients participated in this study. Most were interested in a medicine delivery service (80.2%) and were willing to use a mobile application to order their medicines (84.5%). Almost all patients (96.8%) preferred that their medicines be delivered to their home. More than three quarters of participants were willing to pay for the service (77.6%). Chi-square test showed that gender, age group, employment status, distance to the health facility and /or average waiting time at the clinic significantly influenced the preference for certain characteristics of the medicine delivery service (p < 0.05).

Conclusion

Most participants were interested in a last kilometre medicine delivery service, especially those older than 45 years, waiting for more than 6 h at the facility, and staying within one kilometre radius of the clinic. More studies are needed to establish the influence of patients’ employment status and the distance to health facility on interest in the medicine delivery service.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-021-01392-1.

Peer Recruitment Strategies for Female Sex Workers Not Engaged in HIV Prevention and Treatment Services in Côte d'Ivoire: Program Data Analysis

Background

In the context of the mostly generalized HIV epidemic in Côte d’Ivoire, key populations bear a higher burden of HIV than that borne by the general reproductive-aged population. Mathematical models have demonstrated the significant potential impact and cost-effectiveness of improving the coverage of HIV prevention and treatment services for key populations in Côte d’Ivoire. However, in 2019, coverage of these services remained limited by multiple intersecting stigmas affecting key populations, necessitating the study of innovative implementation strategies to better meet the needs of those most marginalized. Here, we leverage programmatic data to compare the effectiveness of the enhanced and traditional peer outreach approaches in reaching and providing community HIV testing to female sex workers not readily engaged in HIV prevention and treatment services in Côte d’Ivoire.

Objective

The aim of this study was to describe the characteristics of female sex workers reached by the LINKAGES project in Côte d’Ivoire with enhanced peer outreach and traditional peer outreach and to compare HIV-related outcomes between the women reached by both strategies.

Methods

Deidentified routine programmatic data collected as part of LINKAGES Côte d’Ivoire between October 2017 and April 2018 were used in these analyses. Demographic characteristics and HIV indicators including HIV testing history, HIV case-finding, linkage to HIV treatment, and treatment initiation were assessed using descriptive statistics. Differences in these indicators were compared by outreach strategy using Pearson chi-square tests.

Results

There were 9761 women reached with enhanced peer outreach and routine peer outreach included in these analyses. The overall case-finding rate in the sample was 7.8% (698/8851). Compared with women reached by routine outreach, those reached by enhanced peer outreach were more likely to have previously been tested for HIV (enhanced: 1695/2509, 67.6%; routine: 4302/7252, 60.0%; χ²₁=43.8; P=.001). The enhanced peer outreach approach was associated with a higher HIV case-finding rate (enhanced: 269/2507 10.7%; routine: 429/6344, 6.8%; χ²₁=32.3; P=.001), higher proportion of linkage to treatment (enhanced: 258/269, 95.9%; routine: 306/429, 71.3%; χ²₁=64.4; P=.001), and higher proportion of treatment initiation (enhanced: 212/269, 78.8%; routine: 315/429, 73.3%; χ²₁=2.6; P=.11). Women reached by both approaches were categorized as high risk for HIV-related behaviors such as condomless sex and number of sex acts in the previous week.

Conclusions

These analyses suggest that the novel peer-referral strategy, the enhanced peer outreach approach, was effective in reaching female sex workeres in Côte d’Ivoire with demonstrated acquisition risks for HIV and who had not been effectively engaged by routine outreach approaches. Scaling up novel strategies such as enhanced peer outreach in the context of differentiated service models may be needed to optimize HIV prevention and treatment outcomes for key populations in Côte d’Ivoire.

Vulnerability profiles and prevalence of HIV and other sexually transmitted infections among adolescent girls and young women in Ethiopia: A latent class analysis

Background

Adolescent girls and young women (AGYW) aged 15–24 years have among the highest risk for HIV and other sexually transmitted infections (STI) across sub-Saharan Africa. A latent class analysis (LCA) was conducted to identify intersecting social- and structural-level determinants of HIV/STI acquisition among AGYW in Ethiopia.

Methods

AGYW were recruited from venues using time-location sampling, completing an interviewer-administered behavioral survey and biological testing for HIV, syphilis, and chlamydia. LCA was used to identify distinct groups, defined by social- and structural-level determinants of HIV/STI risk, among AGYW. Prevalence ratios (PR) and 95% confidence intervals (CI) compared differences in HIV/STI prevalence by group.

Results

A total of 1,501 AGYW were enrolled across Addis Ababa (March–May 2018) and Gambella (June–July 2019). We identified three patterns of vulnerability defined by schooling status, migration history, food insecurity, orphan status, social support, and employment. We labeled these groups as “highly vulnerable” (representing ~21% of the population), “stable, out-of-school, migrated” (~42%), and “stable, in-school, never migrated” (~37%). STI prevalence was nearly two-fold higher among AGYW in the “highly vulnerable” group compared to AGYW in the “stable, in-school, never migrated” group (PR 1.93; 95% CI 1.33, 2.80).

Conclusions

Characterizing patterns of vulnerability among AGYW that reflect higher-level social and structural factors can help facilitate early identification of AGYW at the highest risk of HIV/STI acquisition, thus differentiating groups of AGYW who may most benefit from targeted HIV prevention interventions during adolescence and early adulthood.

Understanding implementation barriers in the national scale-up of differentiated ART delivery in Uganda

BACKGROUND

Although Differentiated Service Delivery (DSD) for anti-retroviral therapy (ART) has been rolled-out nationally in several countries since World Health Organization (WHO)'s landmark 2016 guidelines, there is little research evaluating post-implementation outcomes. The objective of this study was to explore patients' and HIV service managers' perspectives on barriers to implementation of Differentiated ART service delivery in Uganda.

METHODS

We employed a qualitative descriptive design involving 124 participants. Between April and June 2019 we conducted 76 qualitative interviews with national-level HIV program managers (n = 18), District Health Team leaders (n = 24), representatives of PEPFAR implementing organizations (11), ART clinic in-charges (23) in six purposively selected Uganda districts with a high HIV burden (Kampala, Luwero, Wakiso, Mbale, Budadiri, Bulambuli). Six focus group discussions (48 participants) were held with patients enrolled in DSD models in case-study districts. Data were analyzed by thematic approach as guided by a multi-level analytical framework: Individual-level factors; Health-system factors; Community factors; and Context.

RESULTS

Our data shows that multiple barriers have been encountered in DSD implementation. Individual-level: Individualized stigma and a fear of detachment from health facilities by stable patients enrolled in community-based models were reported as bottlenecks. Socio-economic status was reported to have an influence on patient selection of DSD models. Health-system: Insufficient training of health workers in DSD delivery and supply chain barriers to multi-month ART dispensing were identified as constraints. Patients perceived current selection of DSD models to be provider-intensive and not sufficiently patient-centred. Community: Community-level stigma and insufficient funding to providers to fully operationalize community drug pick-up points were identified as limitations.

CONTEXT

Frequent changes in physical addresses among urban clients were reported to impede the running of patient groups of rotating ART refill pick-ups.

CONCLUSION

This is one of the first multi-stakeholder evaluations of national DSD implementation in Uganda since initial roll-out in 2017. Multi-level interventions are needed to accelerate further DSD implementation in Uganda from demand-side (addressing HIV-related stigma, community engagement) and supply-side dimensions (strengthening ART supply chain capacities, increasing funding for community models and further DSD program design to improve patient-centeredness).

Optimizing differentiated treatment models for people living with HIV in urban Zimbabwe: Findings from a mixed methods study

INTRODUCTION

Zimbabwe is scaling up HIV differentiated service delivery (DSD) to improve treatment outcomes and health system efficiencies. Shifting stable patients into less-intensive DSD models is a high priority in order to accommodate the large numbers of newly-diagnosed people living with HIV (PLHIV) needing treatment and to provide healthcare workers with the time and space needed to treat people with advanced HIV disease. DSD is also seen as a way to improve service quality and enhance retention in care. National guidelines support five differentiated antiretroviral treatment models (DART) for stable HIV-positive adults, but little is known about patient preferences, a critical element needed to guide DART scale-up and ensure person-centered care. We designed a mixed-methods study to explore treatment preferences of PLHIV in urban Zimbabwe.

METHODS

The study was conducted in Harare, and included 35 health care worker (HCW) key informant interviews (KII); 8 focus group discussions (FGD) with 54 PLHIV; a discrete choice experiment (DCE) in which 500 adult DART-eligible PLHIV selected their preferences for health facility (HF) vs. community location, individual vs. group meetings, provider cadre and attitude, clinic operation times, visit frequency, visit duration and cost to patient; and a survey with the 500 DCE participants exploring DART knowledge and preferences.

RESULTS

Patient preferences were consistent in the FGDs, DCE and survey. Participants strongly preferred respectful HCWs, HF-based services, individual DART models, and less costly services. Patients also preferred less frequent visits and shorter wait times. They were indifferent to variations in HCW cadre and distances from home to HF. These preferences were mostly homogenous, with only minor differences between male vs. female and older vs. younger patients. HCWs in the KII correctly characterized facility-based individual models as the one most favored by patients; HCWs also preferred this model, which they felt decongested HFs and reduced their workload.

CONCLUSIONS

DART-eligible PLHIV in Harare found it relatively easy to access HFs, and preferred attributes associated with facility-based individual models. Prioritizing these for scale-up in urban areas may be the most efficient way to sustain positive patient outcomes and increase health system performance.

Implementing quality improvement in tuberculosis programming: Lessons learned from the global HIV response

The quality of care and treatment for tuberculosis (TB) is a major barrier in global efforts to end TB as a global health emergency. Despite a growing recognition of the need to measure, assure, and improve quality of TB services, implementation of quality improvement (QI) activities remains limited. Applying principles of systems thinking, continuous measurement, and root cause analysis, QI represents a proven approach for identifying and addressing performance gaps in healthcare delivery, with demonstrated success in low- and middle-income settings in the areas of HIV/AIDS, maternal, newborn, and child health, and infection control, among others. Drawing from lessons learned in the development of QI programming as part of the global response to HIV, we review key enablers to implementation that may assist NTPs in turning aspirations of high-quality service delivery into action. Under the umbrella of a formal quality management (QM) program, NTPs' attention to planning and coordination, commitment to tracking key processes of care, investment in QI capacity building, and integration of TB QI activities within efforts to advance universal health coverage provide a framework to sustainably implement QI activities.