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Gittings L, Hodes R, Kom P, Mbula S, Pantelic M. 'Remember there is that thing called confidentiality': experiences of institutional discrimination in the health system among adolescent boys and young men living with HIV in the Eastern Cape province of South Africa. CULTURE, HEALTH & SEXUALITY 2024; 26:575-587. [PMID: 37480578 DOI: 10.1080/13691058.2023.2232023] [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: 12/18/2022] [Accepted: 06/28/2023] [Indexed: 07/24/2023]
Abstract
Adolescents and men are two populations that perform poorly within the HIV cascade of care, having worse AIDS-related health outcomes, and experiencing higher levels of HIV-related stigma. This paper explores institutional health system discrimination as experienced by adolescent boys with perinatally-acquired HIV, situating them within the social and gendered contexts of the Eastern Cape Province, South Africa. Life history narratives (n = 36) and in-depth semi-structured interviews (n = 32) with adolescent boys living with HIV aged 13-22 were conducted in 2017-2018. In-depth semi-structured interviews with biomedical and traditional health practitioners (n = 14), analysis of health facility files (n = 41) and clinic observations were also conducted. Together, triangulated sources point to an incongruence between the complex needs of adoelscent boys and young men living with HIV and their experiences within the health system. Two institutional discrimination-related deterrents to retention in care were identified: (1) lack of confidentiality due to health facility layouts and practices that visibilised people living with HIV; and (2) mistreatment in the form of shouting. This article contributes to the limited literature on the experiences of young men within the HIV continuum of care, focusing on how stigma influences how young men experience and engage with the health sector.
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Affiliation(s)
- Lesley Gittings
- School of Health Studies, Faculty of Health Sciences, Western University, London, Canada
- Centre for Social Science Research, University of Cape Town, Cape Town, South Africa
| | - Rebecca Hodes
- Department of Anthropology, Archaeology and Social Development, Humanities Faculty, Pretoria University, South Africa
| | - Phakamani Kom
- Oxford Research South Africa, East London, South Africa
| | | | - Marija Pantelic
- Department of Primary Care and Public Health, Brighton and Sussex Medical School, University of Sussex, Falmer, UK
- Department of Social Policy and Intervention, University of Oxford, Oxford, UK
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Dadi TL, Wiemers AMC, Tegene Y, Medhin G, Spigt M. Experiences of people living with HIV in low- and middle-income countries and their perspectives in self-management: a meta-synthesis. AIDS Res Ther 2024; 21:7. [PMID: 38297363 PMCID: PMC10829476 DOI: 10.1186/s12981-024-00595-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 01/17/2024] [Indexed: 02/02/2024] Open
Abstract
INTRODUCTION Availability of anti-retroviral treatment has changed HIV in to a manageable chronic disease, making effective self-management essential. However, only a few studies in low- and middle-income countries (LMICs) reported experiences of people living with HIV (PLWH) on self-management. METHODS This meta-synthesis of qualitative studies investigated perspectives of PLWH in LMICs on self-management. Various databases, including PubMed, EMBASE, EBSCO, and CINHAL, were searched through June 2022. Relevant additional articles were also included using cross-referencing of the identified papers. We used a thematic synthesis guided by the "Model of the Individual and Family Self-Management Theory" (IFSMT). RESULT PLWH in LIMICs experience a variety of challenges that restrict their options for effective self-management and compromises their quality of life. The main ones include: misconceptions about the disease, poor self-efficacy and self-management skills, negative social perceptions, and a non-patient-centered model of care that reduces the role of patients. The experiences that influenced the ability to practice self-management are summarized in context (the condition itself, physical and environmental factors, individual and family factors) and process factors (knowledge and beliefs, relationship with the health care worker, self-regulation skills and abilities, and social facilitation). Context and process greatly impacted quality of life through the self-management practices of the patients. CONCLUSION AND RECOMMENDATION PLWH encounter multiple challenges, are not empowered enough to manage their own chronic condition, and their needs beyond medical care are not addressed by service providers. Self-management practice of these patients is poor, and service providers do not follow service delivery approaches that empower patients to be at the center of their own care and to achieve an effective and sustainable outcome from treatment. These findings call for a comprehensive well thought self-management interventions.
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Affiliation(s)
- Tegene Legese Dadi
- School of Public Health, College of Medicine & Health Science, Hawassa University, Hawassa, Ethiopia.
- Faculty of Health, Medicine and Life Sciences, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, Netherlands.
| | - Anja M C Wiemers
- Faculty of Health, Medicine and Life Sciences, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, Netherlands
| | - Yadessa Tegene
- School of Public Health, College of Medicine & Health Science, Hawassa University, Hawassa, Ethiopia
- Faculty of Health, Medicine and Life Sciences, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, Netherlands
| | - Girmay Medhin
- Aklilu Lemma Institute of Pathobiology, Addis Ababa University, Addis Ababa, Ethiopia
- MERQ Consultancy PLC, Addis Ababa, Ethiopia
| | - Mark Spigt
- Faculty of Health, Medicine and Life Sciences, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, Netherlands
- General Practice Research Unit, Department of Community Medicine, UiT the Arctic University of Norway, Tromsö, Norway
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Lissouba P, Rücker SCM, Otieno LA, Akatukwasa C, Xulu S, Monjane C, Akinyi M, Okal B, Lubega AV, Stewart R, Bossard C, Ohler L, Antabak NT, Musoke M, Muyindike W, Huerga H. Experiences and perceptions of urine sampling for tuberculosis testing among HIV patients: a multisite qualitative descriptive study. BMJ Open 2023; 13:e058805. [PMID: 38035738 PMCID: PMC10689410 DOI: 10.1136/bmjopen-2021-058805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 10/27/2023] [Indexed: 12/02/2023] Open
Abstract
OBJECTIVES Evidence on the acceptability of urine-based assays for tuberculosis (TB) diagnosis among patients remains limited. We sought to describe patients' experiences and perceptions of urine sampling for TB testing at point of care. SETTING Study sites in Kenya, Uganda, Mozambique and South Africa. PARTICIPANTS Adult ambulatory HIV patients enrolled in a TB diagnostic study were selected purposively. INTERVENTION For this qualitative descriptive study, audiorecorded individual interviews conducted with consenting participants were translated, transcribed and analysed using content analysis. Ethical agreement was obtained from relevant ethical review committees. RESULTS Fifty-eight participants were interviewed. Three domains were identified. Overall, participants described urine sampling as easy, rapid and painless, with the main challenge being lacking the urge. Urine was preferred to sputum sampling in terms of simplicity, comfort, stigma reduction, convenience and practicality. While perceptions regarding its trustworthiness for TB diagnosis differed, urine sampling was viewed as an additional mean to detect TB and beneficial for early diagnosis. Participants were willing to wait for several hours for same-day results to allay the emotional, physical and financial burden of having to return to collect results, and would rather not pay for the test. Facilitators of urine sampling included cleanliness and perceived privacy of sampling environments, comprehensive sampling instructions and test information, as well as supplies such as toilet paper and envelopes ensuring confort and privacy when producing and returning samples. Participants motivation for accepting urine-based TB testing stemmed from their perceived susceptibility to TB, the value they attributed to their health, especially when experiencing symptoms, and their positive interactions with the medical team. CONCLUSIONS This study suggests that urine sampling is well accepted as a TB diagnostic method and provides insights on how to promote patients' uptake of urine-based testing and improve their sampling experiences. These results encourage the future broad use of urine-based assays at point of care.
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Affiliation(s)
- Pascale Lissouba
- Field Epidemiology and Training Department, Epicentre, Paris, France
| | | | - Lucy Atieno Otieno
- Médecins Sans Frontières, Homa Bay, Kenya
- Center for Global Health Research, KEMRI, Kisumu, Kenya
| | | | - Sibongiseni Xulu
- Médecins Sans Frontières, Eshowe, South Africa
- Africa Health Research Institute (AHRI), Somkhele, South Africa
- School of Psychology, University of Kwa-Zulu Natal (UKZN), Durban, South Africa
| | | | | | - Beryl Okal
- Médecins Sans Frontières, Homa Bay, Kenya
| | | | | | - Claire Bossard
- Field Epidemiology and Training Department, Epicentre, Paris, France
| | | | | | | | - Winnie Muyindike
- Epicentre, Mbarara, Uganda
- Mbarara University of Science and Technology (MUST), Mbarara, Uganda
- Mbarara Regional Referral Hospital (MRRH), Mbarara, Uganda
| | - Helena Huerga
- Field Epidemiology and Training Department, Epicentre, Paris, France
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Nardell MF, Sindelo S, Rousseau E, Siko N, Fuzile P, Julies R, Bassett IV, Mellins CA, Bekker LG, Butler LM, Katz IT. Development of "Yima Nkqo," a community-based, peer group intervention to support treatment initiation for young adults with HIV in South Africa. PLoS One 2023; 18:e0280895. [PMID: 37319250 PMCID: PMC10270624 DOI: 10.1371/journal.pone.0280895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 01/11/2023] [Indexed: 06/17/2023] Open
Abstract
AIMS Half of young adults diagnosed with HIV in South Africa start antiretroviral therapy (ART). We developed and field tested a facilitator-guided peer support group called Yima Nkqo ("Standing Tall" in isiXhosa) to promote treatment initiation for young adults newly diagnosed with HIV in communities around Cape Town. METHODS Following an adapted version of the UK Medical Research Council's framework for developing complex interventions, we 1) identified evidence on previous interventions to improve ART uptake in sub-Saharan Africa; 2) collected and analyzed qualitative data on the acceptability of our proposed intervention; 3) proposed a theoretical understanding of the process of behavior change; and 4) developed an intervention manual and feedback tools. During field-testing, participant feedback on intervention acceptability, and team feedback on consistency of content delivery and facilitation quality, were analyzed using an iterative, rapid-feedback evaluation approach. In-depth written and verbal summaries were shared in weekly team meetings. Team members interpreted feedback, identified areas for improvement, and proposed suggestions for intervention modifications. RESULTS Based on our formative research, we developed three, 90-minute sessions with content including HIV and ART education, reflection on personal resources and strengths, practice disclosing one's status, strategies to overcome stressors, and goal setting to start treatment. A lay facilitator was trained to deliver intervention content. Two field testing groups (five and four participants, respectively) completed the intervention. Participants highlighted that strengths of Yima Nkqo included peer support, motivation, and education about HIV and ART. Team feedback to the facilitator ensured optimal consistency of intervention content delivery. CONCLUSIONS Iteratively developed in collaboration with youth and healthcare providers, Yima Nkqo is a promising new intervention to improve treatment uptake among young adults with HIV in South Africa. The next phase will be a pilot randomized controlled trial of Yima Nkqo (ClinicalTrials.gov Identifier: NCT04568460).
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Affiliation(s)
- Maria F. Nardell
- Division of Global Health Equity, Brigham and Women’s Hospital, Boston, MA, United States of America
- Harvard Medical School, Boston, MA, United States of America
- Department of Medicine, Brigham and Women’s Hospital, Boston, MA, United States of America
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States of America
| | - Siyaxolisa Sindelo
- The Desmond Tutu Health Foundation, University of Cape Town, Cape Town, Republic of South Africa
| | - Elzette Rousseau
- The Desmond Tutu Health Foundation, University of Cape Town, Cape Town, Republic of South Africa
| | - Nomakaziwe Siko
- The Desmond Tutu Health Foundation, University of Cape Town, Cape Town, Republic of South Africa
| | - Pamela Fuzile
- The Desmond Tutu Health Foundation, University of Cape Town, Cape Town, Republic of South Africa
| | - Robin Julies
- The Desmond Tutu Health Foundation, University of Cape Town, Cape Town, Republic of South Africa
| | - Ingrid V. Bassett
- Harvard Medical School, Boston, MA, United States of America
- Center for Global Health, Massachusetts General Hospital, Boston, MA, United States of America
| | - Claude A. Mellins
- HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute and Columbia University, New York, NY, United States of America
| | - Linda-Gail Bekker
- The Desmond Tutu Health Foundation, University of Cape Town, Cape Town, Republic of South Africa
- Department of Medicine, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, Republic of South Africa
- Governing Council, International AIDS Society, Geneva, Switzerland
| | - Lisa M. Butler
- Institute for Collaboration on Health, Intervention and Policy, University of Connecticut, Storrs, CT, United States of America
| | - Ingrid T. Katz
- Harvard Medical School, Boston, MA, United States of America
- Department of Medicine, Brigham and Women’s Hospital, Boston, MA, United States of America
- Harvard Global Health Institute, Harvard University, Cambridge, MA, United States of America
- Division of Women’s Health, Brigham and Women’s Hospital, Boston, MA, United States of America
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Abbas S, Kermode M, Khan MD, Denholm J, Adetunji H, Kane S. What Makes People With Chronic Illnesses Discontinue Treatment? A Practice Theory Informed Analysis of Adherence to Treatment among Patients With Drug-Resistant Tuberculosis in Pakistan. Int J Health Policy Manag 2023; 12:6576. [PMID: 37579474 PMCID: PMC10125133 DOI: 10.34172/ijhpm.2022.6576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 12/27/2022] [Indexed: 08/16/2023] Open
Abstract
BACKGROUND Non-adherence to treatment is a frequently observed phenomenon amongst those on long-term treatment for chronic illnesses. This qualitative study draws upon the tenets of 'practice theory' to reveal what shapes patients' ability to adhere to the demanding treatment for drug-resistant tuberculosis (DR-TB) at three treatment sites in Khyber-Pakhtunkhwa (KP) province of Pakistan. METHODS This qualitative study involved observation of service provision over a period of nine months of stay at, and embedment within the three treatment sites and in-depth interviews with 13 service providers and 22 patients who became non-adherent to their treatment. RESULTS Consistent with the extensive research based on the barriers and facilitator approach, both patients, and providers in our study also talked of patients' doubts about diagnosis and treatment efficacy, side-effects of drugs, economic constraints, unreliable disbursements of monetary incentive, attitude of providers and co-morbidities as reasons for non-adherence to treatment. Applying a practice theory perspective yielded more contextualised insights; inadequate help with patients' physical complaints, unempathetic responses to their queries, and failure to provide essential information, created conditions which hindered the establishment and maintenance of the 'practice' of adhering to treatment. These supply-side gaps created confusion, bred resentment, and exacerbated pre-existing distrust of public health services among patients, and ultimately drove them to disengage with the TB services and stop their treatment. CONCLUSION We argue that the lack of supply-side 'responsiveness' to patient needs beyond the provision of a few material inputs is what is lacking in the existing DR-TB program in Pakistan. We conclude that unless Pakistan's TB program explicitly engages with these supply side, system level gaps, patients will continue to struggle to adhere to their treatments and the TB program will continue to lose patients. Conceptually, we make a case for reimagining the act of adherence (or not) to long-term treatment as a 'Practice.'
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Affiliation(s)
- Shazra Abbas
- Nossal Institute for Global Health, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, VIC, Australia
| | - Michelle Kermode
- Nossal Institute for Global Health, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, VIC, Australia
| | | | - Justin Denholm
- Department of Infectious Diseases, University of Melbourne, Melbourne, VIC, Australia
| | - Hamed Adetunji
- Faculty of Public Health & Health Informatics, Umm Al Qura University, Makkah Almukarramah, Saudi Arabia
| | - Sumit Kane
- Nossal Institute for Global Health, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, VIC, Australia
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Gittings L, Colvin C, Hodes R. Traditional and biomedical health practices of adolescent boys and young men living with perinatally-acquired HIV in the Eastern Cape Province of South Africa. Glob Public Health 2023; 18:2205917. [PMID: 37156226 PMCID: PMC10660542 DOI: 10.1080/17441692.2023.2205917] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 04/11/2023] [Indexed: 05/10/2023]
Abstract
Men are less vulnerable to HIV acquisition than women, but have poorer HIV-related health outcomes. They access HIV services less, and are more likely to die on antiretroviral therapy. The adolescent epidemic presents further challenges, and AIDS-related illness is the leading cause of death among adolescents in sub-Saharan Africa. We explored the health practices of adolescent boys and young men (aged 13-22) living with perinatally-acquired HIV and the processes through which these practices are formed and sustained. We engaged health-focused life history narratives (n = 35), semi-structured interviews (n = 32) and analysis of health facility files (n = 41), alongside semi-structured interviews with traditional and biomedical health practitioners (n = 14) in the Eastern Cape, South Africa. Participants did not access traditional products and services for HIV, a finding that deviates from much of the literature. Findings suggest that health practices are mediated not only by gender and culture, but also childhood experiences of growing up deeply embedded in the biomedical health system.
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Affiliation(s)
- Lesley Gittings
- School of Health Studies, Faculty of Health Sciences, Western University, London, Canada
- Centre for Social Science Research, University of Cape Town, Cape Town, South Africa
| | - Christopher Colvin
- Department of Public Health Sciences, University of Virginia, Charlottesville, VA, USA
- Division of Social and Behavioural Sciences, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
- Department of Epidemiology, Brown University, Providence, RI, USA
| | - Rebecca Hodes
- Centre for Sexualities, AIDS & Gender, University of Pretoria, Pretoria, South Africa
- Department of Historical and Heritage Studies, University of Pretoria, Pretoria, South Africa
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Maaløe N, Housseine N, Sørensen JB, Obel J, Sequeira DMello B, Kujabi ML, Osaki H, John TW, Khamis RS, Muniro ZSS, Nkungu DJ, Pinkowski Tersbøl B, Konradsen F, Mookherji S, Mbekenga C, Meguid T, van Roosmalen J, Bygbjerg IC, van den Akker T, Jensen AK, Skovdal M, L. Kidanto H, Wolf Meyrowitsch D. Scaling up context-tailored clinical guidelines and training to improve childbirth care in urban, low-resource maternity units in Tanzania: A protocol for a stepped-wedged cluster randomized trial with embedded qualitative and economic analyses (The PartoMa Scale-Up Study). Glob Health Action 2022; 15:2034135. [PMID: 35410590 PMCID: PMC9009913 DOI: 10.1080/16549716.2022.2034135] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Accepted: 01/21/2022] [Indexed: 11/04/2022] Open
Abstract
While facility births are increasing in many low-resource settings, quality of care often does not follow suit; maternal and perinatal mortality and morbidity remain unacceptably high. Therefore, realistic, context-tailored clinical support is crucially needed to assist birth attendants in resource-constrained realities to provide best possible evidence-based and respectful care. Our pilot study in Zanzibar suggested that co-created clinical practice guidelines (CPGs) and low-dose, high-frequency training (PartoMa intervention) were associated with improved childbirth care and survival. We now aim to modify, implement, and evaluate this multi-faceted intervention in five high-volume, urban maternity units in Dar es Salaam, Tanzania (approximately 60,000 births annually). This PartoMa Scale-up Study will include four main steps: I. Mixed-methods situational analysis exploring factors affecting care; II. Co-created contextual modifications to the pilot CPGs and training, based on step I; III. Implementation and evaluation of the modified intervention; IV. Development of a framework for co-creation of context-specific CPGs and training, of relevance in comparable fields. The implementation and evaluation design is a theory-based, stepped-wedged cluster-randomised trial with embedded qualitative and economic assessments. Women in active labour and their offspring will be followed until discharge to assess provided and experienced care, intra-hospital perinatal deaths, Apgar scores, and caesarean sections that could potentially be avoided. Birth attendants' perceptions, intervention use and possible associated learning will be analysed. Moreover, as further detailed in the accompanying article, a qualitative in-depth investigation will explore behavioural, biomedical, and structural elements that might interact with non-linear and multiplying effects to shape health providers' clinical practices. Finally, the incremental cost-effectiveness of co-creating and implementing the PartoMa intervention is calculated. Such real-world scale-up of context-tailored CPGs and training within an existing health system may enable a comprehensive understanding of how impact is achieved or not, and how it may be translated between contexts and sustained.Trial registration number: NCT04685668.
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Affiliation(s)
- Nanna Maaløe
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- Department of Obstetrics and Gynaecology, Hvidovre University Hospital, Hvidovre, Denmark
| | - Natasha Housseine
- Medical College East Africa, Aga Khan University, Dar Es Salaam, Tanzania
| | - Jane Brandt Sørensen
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Josephine Obel
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Brenda Sequeira DMello
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- Medical College East Africa, Aga Khan University, Dar Es Salaam, Tanzania
- Comprehensive Community Based Rehabilitation in Tanzania, Dar Es Salaam, Tanzania
| | - Monica Lauridsen Kujabi
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Haika Osaki
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- Medical College East Africa, Aga Khan University, Dar Es Salaam, Tanzania
| | - Thomas Wiswa John
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- Medical College East Africa, Aga Khan University, Dar Es Salaam, Tanzania
| | - Rashid Saleh Khamis
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- Medical College East Africa, Aga Khan University, Dar Es Salaam, Tanzania
| | | | | | - Britt Pinkowski Tersbøl
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Flemming Konradsen
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Sangeeta Mookherji
- Department of Global Health, George Washington University Milken Institute School of Public Health, Washington, DC, USA
| | - Columba Mbekenga
- School of Nursing and Midwifery East Africa, Aga Khan University, Dar Es Salaam, Tanzania
| | | | - Jos van Roosmalen
- Athena Institute, VU University, Amsterdam, Netherlands
- Department of Obstetrics and Gynaecology, Leiden University Medical Centre, Leiden, Netherlands
| | - Ib Christian Bygbjerg
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Thomas van den Akker
- Athena Institute, VU University, Amsterdam, Netherlands
- Department of Obstetrics and Gynaecology, Leiden University Medical Centre, Leiden, Netherlands
| | - Andreas Kryger Jensen
- Section for Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Morten Skovdal
- Section for Health Services Research, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Hussein L. Kidanto
- Medical College East Africa, Aga Khan University, Dar Es Salaam, Tanzania
| | - Dan Wolf Meyrowitsch
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
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Burns R, Venables E, Odhoch L, Kocholla L, Wanjala S, Mucinya G, Bossard C, Wringe A. Slipping through the cracks: a qualitative study to explore pathways of HIV care and treatment amongst hospitalised patients with advanced HIV in Kenya and the Democratic Republic of the Congo. AIDS Care 2022; 34:1179-1186. [PMID: 34445917 DOI: 10.1080/09540121.2021.1966697] [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: 01/26/2023]
Abstract
Advanced HIV causes substantial mortality in sub-Saharan Africa despite widespread antiretroviral therapy coverage. This paper explores pathways of care amongst hospitalised patients with advanced HIV in rural Kenya and urban Democratic Republic of the Congo, with a view to understanding their care-seeking trajectories and poor health outcomes. Thirty in-depth interviews were conducted with hospitalised patients with advanced HIV who had previously initiated first-line antiretroviral therapy, covering their experiences of living with HIV and care-seeking. Interviews were audio-recorded, transcribed and translated before being coded inductively and analysed thematically. In both settings, participants' health journeys were defined by recurrent, severe symptoms and complex pathways of care before hospitalisation. Patients were often hospitalised after multiple failed attempts to obtain adequate care at health centres. Most participants managed their ill-health with limited support networks, lived in fragile economic situations and often experienced stress and other mental health concerns. Treatment-taking was sometimes undermined by strict messaging around adherence that was delivered in health facilities. These findings reveal a group of patients who had "slipped through the cracks" of health systems and social support structures, indicating both missed opportunities for timely management of advanced HIV and the need for interventions beyond hospital and clinical settings.
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Affiliation(s)
- Rose Burns
- Epicentre, Médecins sans Frontières, Paris, France
| | - Emilie Venables
- Southern Africa Medical Unit: Médecins Sans Frontières, Cape Town, South Africa.,University of Cape Town, Cape Town, South Africa
| | | | - Lilian Kocholla
- Homabay County Teaching and Referral Hospital, Homa Bay, Kenya
| | | | - Gisele Mucinya
- Médecins Sans Frontières, Kinshasa, Democratic Republic of the Congo
| | | | - Alison Wringe
- London School of Hygiene and Tropical Medicine, London, UK
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Myers C, Apondi E, Toromo JJ, Omollo M, Bakari S, Aluoch J, Sang F, Njoroge T, Morris Z, Kantor R, Braitstein P, Nyandiko WM, Wools-Kaloustian K, Elul B, Vreeman RC, Enane LA. "Who am I going to stay with? Who will accept me?": family-level domains influencing HIV care engagement among disengaged adolescents in Kenya. J Int AIDS Soc 2022; 25:e25890. [PMID: 35192747 PMCID: PMC8863355 DOI: 10.1002/jia2.25890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 02/01/2022] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Adolescents living with HIV (ALHIV, ages 10-19) have developmentally specific needs in care, and have lower retention compared to other age groups. Family-level contexts may be critical to adolescent HIV outcomes, but have often been overlooked. We investigated family-level factors underlying disengagement and supporting re-engagement among adolescents disengaged from HIV care. METHODS Semi-structured interviews were performed with 42 disengaged ALHIV, 32 of their caregivers and 28 healthcare workers (HCW) in the Academic Model Providing Access to Healthcare (AMPATH) program in western Kenya, from 2018 to 2020. Disengaged ALHIV had ≥1 visit within the 18 months prior to data collection at one of two sites and nonattendance ≥60 days following their last scheduled appointment. HCW were recruited from 10 clinics. Transcripts were analysed through thematic analysis. A conceptual model for family-level domains influencing adolescent HIV care engagement was developed from these themes. RESULTS Family-level factors emerged as central to disengagement. ALHIV-particularly those orphaned by the loss of one or both parents-experienced challenges when new caregivers or unstable living situations limited support for HIV care. These challenges were compounded by anticipated stigma; resultant non-disclosure of HIV status to household members; enacted stigma in the household, with overwhelming effects on adolescents; or experiences of multiple forms of trauma, which undermined HIV care engagement. Some caregivers lacked finances or social support to facilitate care. Others did not feel equipped to support adolescent engagement or adherence. Regarding facilitators to re-engagement, participants described roles for household disclosure; and solidarity from caregivers, especially those also living with HIV. Family-level domains influencing HIV care engagement were conceptualized as follows: (1) adolescent living situation and contexts; (2) household material resources or poverty; (3) caregiver capacities and skills to support adolescent HIV care; and (4) HIV stigma or solidarity at the household level. CONCLUSIONS Family-level factors are integral to retention in care for ALHIV. The conceptual model developed in this study for family-level influences on care engagement may inform holistic approaches to promote healthy outcomes for ALHIV. Developmentally appropriate interventions targeting household relationships, disclosure, HIV stigma reduction, HIV care skills and resources, and economic empowerment may promote adolescent engagement in HIV care.
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Affiliation(s)
- Courtney Myers
- Division of Infectious Diseases, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Edith Apondi
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya.,Moi Teaching and Referral Hospital, Eldoret, Kenya
| | - Judith J Toromo
- The Ryan White Center for Pediatric Infectious Disease and Global Health, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Mark Omollo
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Salim Bakari
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Josephine Aluoch
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Festus Sang
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Tabitha Njoroge
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Zariel Morris
- Indiana University-Purdue University-Indianapolis, Indiana University, Indianapolis, Indiana, USA
| | - Rami Kantor
- Division of Infectious Diseases, Department of Medicine, Brown University Apert Medical School, Providence, Rhode Island, USA
| | - Paula Braitstein
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya.,Department of Epidemiology, Indiana University Fairbanks School of Public Health, Indianapolis, Indiana, USA.,Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,Department of Medicine, School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya
| | - Winstone M Nyandiko
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya.,Department of Child Health and Pediatrics, School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya
| | - Kara Wools-Kaloustian
- Division of Infectious Diseases, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA.,Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya.,Indiana University Center for Global Health, Indianapolis, Indiana, USA
| | - Batya Elul
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Rachel C Vreeman
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya.,Department of Child Health and Pediatrics, School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya.,Department of Health System Design and Global Health, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Arnhold Institute for Global Health, New York, New York, USA
| | - Leslie A Enane
- The Ryan White Center for Pediatric Infectious Disease and Global Health, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA.,Indiana University Center for Global Health, Indianapolis, Indiana, USA
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10
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Service Use and Resilience among Adolescents Living with HIV in Blantyre, Malawi. Int J Integr Care 2021; 21:11. [PMID: 34785995 PMCID: PMC8570195 DOI: 10.5334/ijic.5538] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 06/29/2021] [Indexed: 12/19/2022] Open
Abstract
Introduction: Adolescents living with HIV (ALHIV) experience social and health challenges that warrant the provision of services and relational support to build resilience. Little is known about how social, community and health services help. We examine formal and alternative service use by and resilience of ALHIV participating in an enhanced teen-club clinic (TCC) programme. Description: TCC is an adolescent-centred differentiated care model offering a ‘one-stop-shop’ for HIV/Sexual and Reproductive Health (SRH) services to ALHIV. A survey was conducted with 406 ALHIV to determine frequency of use and satisfaction with services. In addition, we conducted 26 in-depth interviews with ALHIV, 12 group discussions with 144 caregivers, and observations of workshops held for 35 health workers to capture multiple perspectives on service use and relational support systems for adolescent’s wellbeing. Discussion: About 70% of ALHIV were concurrently clients of three or more services. The multi-method analysis showed variations on risks, range of services, frequency of use and satisfaction. Interview data reflected complex factors influencing access to formal services, and caregivers and adolescents also sought alternative care from spiritual and traditional healers. Conclusion: Adolescent centred-approaches have the potential to enhance resilience promoting resources and outcomes. A multi-sectoral approach to service use and provision is critical to inform adolescent intervention programs and wellbeing.
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11
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Testing for saturation in qualitative evidence syntheses: An update of HIV adherence in Africa. PLoS One 2021; 16:e0258352. [PMID: 34665831 PMCID: PMC8525762 DOI: 10.1371/journal.pone.0258352] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Accepted: 09/24/2021] [Indexed: 11/22/2022] Open
Abstract
Background A systematic review of randomised trials may be conclusive signalling no further research is needed; or identify gaps requiring further research that may then be included in review updates. In qualitative evidence synthesis (QES), the rationale, triggers, and methods for updating are less clear cut. We updated a QES on adherence to anti-retroviral treatment to examine if thematic saturation renders additional research redundant. Methods We adopted the original review search strategy and eligibility criteria to identify studies in the subsequent three years. We assessed studies for conceptual detail, categorised as ‘rich’ or ‘sparse’, coding the rich studies. We sought new codes, and appraised whether findings confirmed, extended, enriched, or refuted existing themes. Finally, we examined if the analysis impacted on the original conceptual model. Results After screening 3895 articles, 301 studies met the inclusion criteria. Rich findings from Africa were available in 82 studies; 146 studies were sparse, contained no additional information on specific populations, and did not contribute to the analysis. New studies enriched our understanding on the relationship between external and internal factors influencing adherence, confirming, extending and enriching the existing themes. Despite careful evaluation of the new literature, we did not identify any new themes, and found no studies that refuted our theory. Conclusions Updating an existing QES using the original question confirmed and sometimes enriched evidence within themes but made little or no substantive difference to the theory and overall findings of the original review. We propose this illustrates thematic saturation. We propose a thoughtful approach before embarking on a QES update, and our work underlines the importance of QES priority areas where further primary research may help, and areas where further studies may be redundant.
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12
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Mnyaka OR, Mabunda SA, Chitha WW, Nomatshila SC, Ntlongweni X. Barriers to the Implementation of the HIV Universal Test and Treat Strategy in Selected Primary Care Facilities in South Africa's Eastern Cape Province. J Prim Care Community Health 2021; 12:21501327211028706. [PMID: 34189991 PMCID: PMC8252362 DOI: 10.1177/21501327211028706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: The South African government implemented the Universal Test and Treat (UTT) approach to treating HIV in the second half of 2016. As part of a contribution to the successful implementation of UTT, this study looked at barriers to implementation of UTT emanating from weaknesses of the health system in 2 Community Health Centers in South Africa’s Eastern Cape Province. Methods: This was a quantitative cross-sectional design which had both descriptive and analytical components. Convenience sampling was used to select and recruit 2 primary care facilities and 30 nurses. Self-administered questionnaires were used to solicit data from facility managers and nurses. In addition, a record review was used to access 6 months’ data for the period 1 October 2017 to 31 March 2018. Data were analyzed using Stata 14.1. Categorical data were presented using frequency and contingency tables. The 95% confidence interval (95% CI) is used for the precision of estimates and the P-value of statistical significance is P < .05. Results: Facilities were found to have poor leadership and governance; human resource challenges that include shortages, lack of skills and lack of developmental support; poorly resourced service delivery platforms and poor information management. Of the three 90-90-90 targets, health facilities only satisfactorily achieved the second 90 of initiating all who test positive for HIV within a week (93.1% or n = 288/307). Conclusions: This study has been able to identify potential barriers to the implementation of the UTT strategy at the selected facilities including the lack of structured programs in place to monitor performance of healthcare staff, knowledge gaps, and a lack of good clinical governance practices as evidenced by the lack of customized protocols and Standard Operating Procedures.
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Affiliation(s)
- Onke R Mnyaka
- University of the Witwatersrand, Johannesburg, South Africa
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13
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Williams SM, Renjua J, Moshabela M, Wringe A. Understanding the influence of health systems on women's experiences of Option B+: A meta-ethnography of qualitative research from sub-Saharan Africa. Glob Public Health 2021; 16:167-185. [PMID: 33284727 PMCID: PMC7612946 DOI: 10.1080/17441692.2020.1851385] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Accepted: 11/05/2020] [Indexed: 11/21/2022]
Abstract
We explored women's experiences of Option B+ in sub-Saharan African health facility settings through a meta-ethnography of 32 qualitative studies published between 2010 and 2019. First and second-order constructs were identified from the data and authors' interpretations respectively. Using a health systems lens, third-order constructs explored how the health systems shaped women's experiences of Option B+ and their subsequent engagement in care. Women's experiences of Option B+ services were influenced by their interactions with health workers, which were often reported to be inadequate and rushed, reflecting insufficient staffing or training to address pregnant women's needs. Women's experiences were also undermined by various manifestations of stigma which persisted in the absence of resources for social or mental health support, and were exacerbated by space constraints in health facilities that infringed on patient confidentiality. Sub-optimal service accessibility, drug stock-outs and inadequate tracing systems also shaped women's experiences of care. Strengthening health systems by improving health worker capacity to provide respectful and high-quality clinical and support services, improving supply chains and improving the privacy of consultation spaces would improve women's experiences of Option B+ services, thereby contributing to improved care retention. These lessons should be considered as universal test and treat programmes expand.
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Affiliation(s)
- Shannon M. Williams
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Jenny Renjua
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
- Department of Epidemiology and Biostatistics, Kilimanjaro Christian Medical College, Moshi, Tanzania
| | - Mosa Moshabela
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
- Africa Health Research Institute, Durban, South Africa
| | - Alison Wringe
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
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14
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Abbas S, Kermode M, Kane S. Strengthening the response to drug-resistant TB in Pakistan: a practice theory-informed approach. Public Health Action 2020; 10:147-156. [PMID: 33437680 DOI: 10.5588/pha.20.0030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 10/23/2020] [Indexed: 11/10/2022] Open
Abstract
Background While Pakistan's Programmatic Management of Drug-Resistant Tuberculosis (PMDT) programme, launched in 2010, initially yielded significant gains in treatment outcomes, performance has since plateaued, and in some cases, regressed. Objective To critically investigate why the PMDT programme, well-structured and generously resourced as it is, could not improve upon or sustain this early success and to illustrate the use of practice theory as a framework to analyse functioning of health systems. Method A practice theory-informed ethnographic study was conducted at three PMDT clinics. The analysis drew on 9 months of participant observation and in-depth interviews with 13 healthcare providers and four managers. Results The PMDT model primarily focused on materialities such as infrastructure, drugs and numbers of people tested, and little on developing competencies of the PMDT staff to provide responsive care. This emphasis on materialities, and the linked focus of accountability processes, led the PMDT staff to create meanings that translated into prioritisation of certain easy-to-measure health-care practices at the expense of more difficult-to-measure practices related to responsiveness that are arguably also important for successful patient outcomes. Conclusion A narrow focus on measurable inputs, originating from priorities set at global and national levels, influence frontline care practices with negative consequences for quality of care and patient outcomes. Greater emphasis on improving routine process of care can enhance the effectiveness of the PMDT model of care. Practice theory provides a robust analytical framework to critically interrogate health systems and healthcare provision.
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Affiliation(s)
- S Abbas
- Nossal Institute for Global Health, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, VIC, Australia
| | - M Kermode
- Nossal Institute for Global Health, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, VIC, Australia
| | - S Kane
- Nossal Institute for Global Health, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, VIC, Australia
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15
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Etoori D, Renju J, Reniers G, Ndhlovu V, Ndubane S, Makhubela P, Maritze M, Gomez-Olive FX, Wringe A. 'If the results are negative, they motivate us'. Experiences of early infant diagnosis of HIV and engagement in Option B. Glob Public Health 2020; 16:186-200. [PMID: 32673142 DOI: 10.1080/17441692.2020.1795220] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Few studies have explored the relationship between early infant diagnosis (EID) of HIV and mothers' engagement in care under Option B+. We conducted in-depth interviews with 20 women who initiated antiretroviral therapy (ART) under Option B+ in rural South Africa to explore the interactions between EID and maternal care engagement. Drawing on practice theory, we identified themes relating to Option B+ care engagement and EID. Women's practice of engagement with HIV care shaped their decision-making around EID. Mothers who disengaged from care during pregnancy were less inclined to utilise EID as they lacked information about its availability and benefits. For some mothers, tensions between wanting to breastfeed and perceptions that it could facilitate transmission led to repeated utilisation of EID as reassurance that the child remained negative. Some mothers used their child's negative result as a proxy for their status, subsequently disengaging from care. For some participants, an HIV diagnosis of their infant and the subsequent double burden of treatment visits for themselves and their infant, contributed to their disengagement. Women's care-seeking practices for themselves and their infants work in a symbiotic ecosystem and should be viewed interdependently to tailor interventions to improve EID uptake and Option B+ care engagement.
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Affiliation(s)
- David Etoori
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Jenny Renju
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom.,Department of Epidemiology and Biostatistics, Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Georges Reniers
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom.,MRC/WITS Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Violet Ndhlovu
- 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
| | - Sherly Ndubane
- 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
| | - Princess Makhubela
- 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
| | - Meriam Maritze
- 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
| | - Francesc Xavier Gomez-Olive
- MRC/WITS Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Alison Wringe
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
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16
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Kaunda-Khangamwa BN, Kapwata P, Malisita K, Munthali A, Chipeta E, Phiri S, Manderson L. Adolescents living with HIV, complex needs and resilience in Blantyre, Malawi. AIDS Res Ther 2020; 17:35. [PMID: 32571375 PMCID: PMC7310029 DOI: 10.1186/s12981-020-00292-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 06/11/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Adolescents living with HIV (ALHIV) in Malawi experience multiple challenges associated with their illness and various social, environmental, economic and cultural factors. In exploring their various medical concerns and social vulnerabilities, we consider the role of multiple services in creating a pathway for resilience. METHODS Multiple methods and case studies allowed for triangulation of evidence and provided a holistic understanding of resilience among adolescents with complex needs. The research methods included: (1) a survey to identify examples of young people with complex needs, (2) qualitative interviews and field notes to further explore these needs, (3) patient files and health passports to identify clinical challenges, and (4) ecomapping exercises to personalize cases and identify resilience-enabling resources and supports. We present four case studies to highlight the complex experiences and access to services of ALHIV, and to illustrate their growing power and decision-making capacity over time. RESULTS Adversity experienced by ALHIV varied by gender, family situation, years of schooling, and use of teen-clubs for support. The two female adolescents emphasised their need to be accepted and how this impacted sexuality and reproduction. The two males illustrated how ideas of masculinity influenced their sexual practice and involvement with health services and the correctional justice system. Multiple risks (alcohol use, sexual activities) and complex needs (belonging, having a purpose in life/productive activities, autonomy, desire for offspring) influence pathways to resilience. ALHIV were able to strengthen their own wellbeing by resisting negative behaviours and peer pressure and caregiver interactions through 'strategic silence'. CONCLUSION ALHIV experienced self-transformation as a result of taking ART, with fewer severe episodes of illness and distressing skin conditions. Continuous engagement at the teen-club clinic transformed both productive activities and social relationships among ALHIV as they set life goals, gained a sense of empowerment, requested SRH services, and formed intimate relationships. These transformative opportunities allowed them to learn ways of minimizing risk of reinfection and violence, and of navigating health worker-caregiver-adolescent interactions.
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17
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Dorward J, Msimango L, Gibbs A, Shozi H, Tonkin-Crine S, Hayward G, Butler CC, Ngobese H, Drain PK, Garrett N. Understanding how community antiretroviral delivery influences engagement in HIV care: a qualitative assessment of the Centralised Chronic Medication Dispensing and Distribution programme in South Africa. BMJ Open 2020; 10:e035412. [PMID: 32414827 PMCID: PMC7245406 DOI: 10.1136/bmjopen-2019-035412] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION Providing antiretroviral therapy (ART) for millions of people living with HIV requires efficient, client-centred models of differentiated ART delivery. In South Africa, the Centralised Chronic Medication Dispensing and Distribution (CCMDD) programme allows over 1 million people to collect chronic medication, including ART, from community pick-up points. We aimed to explore how CCMDD influences engagement in HIV care. METHODS We performed in-depth interviews and focus group discussions with clients receiving ART and healthcare workers in Durban, South Africa. We analysed transcripts using deductive thematic analysis, with a framework informed by 'theories of practice', which highlights the materialities, competencies, meanings and other life practices that underpin clients' engagement in HIV care. RESULTS Between March 2018 to August 2018 we undertook 25 interviews and four focus groups with a total of 55 clients, and interviewed eight healthcare workers. The material challenges of standard clinic-based ART provision included long waiting times, poor confidentiality and restricted opening hours, which discouraged clients from engagement. In contrast, CCMDD allowed quicker and more convenient ART collection in the community. This required the development of new competencies around accessing care, and helped change the meanings associated with HIV, by normalising treatment collection. CCMDD was seen as a reward by clients for taking ART well, and helped reduce disruption to other life practices such as employment. At private pharmacies, some clients reported receiving inferior care compared with paying customers, and some worried about inadvertently revealing their HIV status. Clients and healthcare workers had to negotiate problems with CCMDD implementation, including some pharmacies reaching capacity or only allowing ART collection at restricted times. CONCLUSIONS In South Africa, CCMDD overcame material barriers to attending clinics, changed the meanings associated with collecting ART and was less disruptive to other social practices in clients' lives. Expansion of community-based ART delivery programmes may help to facilitate engagement in HIV care. TRIAL REGISTRATION NUMBER STREAM study clinical trial registration: NCT03066128, registered February 2017.
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Affiliation(s)
- Jienchi Dorward
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa
| | - Lindani Msimango
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa
| | - Andrew Gibbs
- Gender and Health Research Unit, South African Medical Research Council, Pretoria, South Africa
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Hlengiwe Shozi
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa
| | - Sarah Tonkin-Crine
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, UK
| | - Gail Hayward
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Christopher C Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Hope Ngobese
- eThekwini Municipality Health Unit, Durban, South Africa
| | - Paul K Drain
- Department of Global Health, Schools of Medicine and Public Health, University of Washington, Seattle, United States
- Department of Medicine, School of Medicine, University of Washington, Seattle, United States
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, United States
| | - Nigel Garrett
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa
- Discipline of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
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18
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Kave S, Khuzwayo NF, Hatcher A, Sikweyiya Y. The role of support groups in linking and retaining newly diagnosed clients in HIV care in a peri-urban location in South Africa. AJAR-AFRICAN JOURNAL OF AIDS RESEARCH 2019; 18:9-17. [PMID: 30880579 DOI: 10.2989/16085906.2018.1551233] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Although South Africa has the largest number of people on antiretroviral therapy (ART) in the world, many HIV clients drop out of care immediately after HIV diagnosis. This qualitative study explored the perceptions and experiences of newly diagnosed clients on the role support groups play in linking and retaining newly diagnosed clients in HIV care in Mbandazayo peri-urban location. The data were analysed using the thematic content analysis approach. Data revealed four mechanisms through which support groups appeared to link and retain newly diagnosed clients in the HIV care continuum. First, support groups were a formal link between newly diagnosed clients and health facilities. Second, support groups mitigated the effects of both felt and enacted stigma, thereby facilitating acceptance of HIV diagnosis among newly diagnosed clients. Third, support groups were an advocacy and networking tool for newly diagnosed clients to make their health related needs, challenges, and concerns known to local health clinics, thereby forging and maintaining a close relationship with their local health facilities. Last, support groups were spaces within the community where practical needs of newly diagnosed clients are met, which in turn help in retaining them within support groups, and facilitate their linkage and retention in the HIV continuum of care in Mbandazayo. Our findings suggest that HIV support groups are critical in enhancing linkages and retention of newly diagnosed clients in HIV care. With the introduction of universal test and treat (UTT) in South Africa, our findings suggest that support groups can play a significant role in retaining HIV care clients who are diagnosed and immediately enrolled on ART.
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Affiliation(s)
- Siyabonga Kave
- a Department of Rural Health , University of KwaZulu-Natal , Durban , South Africa
| | - Nelisiwe F Khuzwayo
- a Department of Rural Health , University of KwaZulu-Natal , Durban , South Africa
| | - Abigail Hatcher
- b School of Public Health , University of the Witwatersrand , Johannesburg , South Africa
| | - Yandisa Sikweyiya
- c Gender & Health Research Unit, School of Public Health , University of the Witwatersrand , Johannesburg , South Africa
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19
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Strategies for engaging men in HIV services. Lancet HIV 2019; 6:e191-e200. [PMID: 30777726 DOI: 10.1016/s2352-3018(19)30032-3] [Citation(s) in RCA: 74] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Revised: 12/20/2018] [Accepted: 12/20/2018] [Indexed: 12/14/2022]
Abstract
The importance of men in the global HIV response is increasingly recognised. In most settings, men are less engaged in HIV services and have worse health outcomes than women. The multiple gender, social, economic, political, and institutional factors behind these patterns are well documented. More recently, researchers have been reporting evidence on strategies aimed at improving the engagement of men in HIV services. Several promising approaches exist, including community-based outreach programmes, gender-transformative interventions to shift gender norms and practices, and the development of more responsive, male-friendly health services. Challenges remain, however, in terms of cost and sustainability, intersecting inequalities like race and class, and the difficulty of changing community-level gender norms. Future research should focus on developing theory-informed interventions and evaluations, on improving the understanding of specific subpopulations of men, and on broadening the evidence base beyond the few countries that produce most research in this field.
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20
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Skovdal M, Ssekubugu R, Nyamukapa C, Seeley J, Renju J, Wamoyi J, Moshabela M, Ondenge K, Wringe A, Gregson S, Zaba B. The rebellious man: Next-of-kin accounts of the death of a male relative on antiretroviral therapy in sub-Saharan Africa. Glob Public Health 2019; 14:1252-1263. [PMID: 30689511 PMCID: PMC6816491 DOI: 10.1080/17441692.2019.1571092] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The HIV response is hampered by many obstacles to progression along the HIV care cascade, with men, in particular, experiencing different forms of disruption. One group of men, whose stories remain untold, are those who have succumbed to HIV-related illness. In this paper, we explore how next-of-kin account for the death of a male relative. We conducted 26 qualitative after-death interviews with family members of male PLHIV who had recently died from HIV in health and demographic surveillance sites in Malawi, Tanzania, Kenya, Uganda, Zimbabwe and South Africa. The next-of-kin expressed frustration about the defiance of their male relative to disclose his HIV status and ask for support, and attributed this to shame, fear and a lack of self-acceptance of HIV diagnosis. Next-of-kin painted a picture of their male relative as rebellious. Some claimed that their deceased relative deliberately ignored instructions received by the health worker. Others described their male relatives as unable to maintain caring relationships that would avail day-to-day treatment partners, and give purpose to their lives. Through these accounts, next-of-kin vocalised the perceived rebellious behaviour of these men, and in the process of doing so neutralised their responsibility for the premature death of their relative.
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Affiliation(s)
- Morten Skovdal
- a Department of Public Health , University of Copenhagen , Copenhagen , Denmark
| | | | - Constance Nyamukapa
- c Biomedical Research and Training Institute , Harare , Zimbabwe.,d Department for Infectious Disease Epidemiology , Imperial College London , London , UK
| | - Janet Seeley
- e London School of Hygiene and Tropic Medicine , London , UK.,f Medical Research Council/Uganda Virus Research Institute , Entebbe , Uganda.,g African Health Research Institute , Durban , South Africa
| | - Jenny Renju
- e London School of Hygiene and Tropic Medicine , London , UK.,h Malawi Epidemiology and Intervention Research Unit , Karonga , Malawi
| | - Joyce Wamoyi
- i National Institute for Medical Research , Mwanza Research Centre, Mwanza , Tanzania
| | - Mosa Moshabela
- g African Health Research Institute , Durban , South Africa.,j University of KwaZulu-Natal , Durban , South Africa
| | | | - Alison Wringe
- e London School of Hygiene and Tropic Medicine , London , UK
| | - Simon Gregson
- c Biomedical Research and Training Institute , Harare , Zimbabwe.,d Department for Infectious Disease Epidemiology , Imperial College London , London , UK
| | - Basia Zaba
- e London School of Hygiene and Tropic Medicine , London , UK
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21
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Burns R, Borges J, Blasco P, Vandenbulcke A, Mukui I, Magalasi D, Molfino L, Manuel R, Schramm B, Wringe A. 'I saw it as a second chance': A qualitative exploration of experiences of treatment failure and regimen change among people living with HIV on second- and third-line antiretroviral therapy in Kenya, Malawi and Mozambique. Glob Public Health 2019; 14:1112-1124. [PMID: 30632883 DOI: 10.1080/17441692.2018.1561921] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Increasing numbers of people living with HIV (PLHIV) in sub-Saharan Africa are experiencing failure of first-line antiretroviral therapy and transitioning onto second-line regimens. However, there is a dearth of research on their treatment experiences. We conducted in-depth interviews with 43 PLHIV on second- or third-line antiretroviral therapy and 15 HIV health workers in Kenya, Malawi and Mozambique to explore patients' and health workers' perspectives on these transitions. Interviews were audio-recorded, transcribed and translated into English. Data were coded inductively and analysed thematically. In all settings, experiences of treatment failure and associated episodes of ill-health disrupted daily social and economic activities, and recalled earlier fears of dying from HIV. Transitioning onto more effective regimens often represented a second (or third) chance to (re-)engage with HIV care, with patients prioritising their health over other aspects of their lives. However, many patients struggled to maintain these transformations, particularly when faced with persistent social challenges to pill-taking, alongside the burden of more complex regimens and an inability to mobilise sufficient resources to accommodate change. Efforts to identify treatment failure and support regimen change must account for these patients' unique illness and treatment histories, and interventions should incorporate tailored counselling and social and economic support.
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Affiliation(s)
| | - Joana Borges
- b Médecins sans Frontières , Geneva , Switzerland
| | | | | | | | | | | | | | | | - Alison Wringe
- f London School of Hygiene and Tropical Medicine , London , UK
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22
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Being HIV positive and staying on antiretroviral therapy in Africa: A qualitative systematic review and theoretical model. PLoS One 2019; 14:e0210408. [PMID: 30629648 PMCID: PMC6328200 DOI: 10.1371/journal.pone.0210408] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 12/21/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Adherence to antiretroviral therapy (ART) and long-term uninterrupted engagement in HIV care is difficult for HIV-positive people, and randomized trials of specific techniques to promote adherence often show small or negligible effects. Understanding what influences decision-making in HIV-positive people in Africa may help researchers and policy makers in the development of broader, more effective interventions and policies. METHODS We used thematic synthesis and a grounded theory approach to generate a detailed narrative and theoretical model reflecting life with HIV in Africa, and how this influences ART adherence and engagement decisions. We included qualitative primary studies that explored perspectives, perceptions and experiences of HIV-positive people, caregivers and healthcare service providers. We searched databases from 1 January 2013 to 9 December 2016, screened all studies, and selected those for inclusion using purposeful sampling methods. Included studies were coded with Atlas.ti, and we assessed methodological quality across five domains. RESULTS We included 59 studies from Africa in the synthesis. Nine themes emerged which we grouped under three main headings. First, people who are HIV-positive live in a complicated world where they must navigate the challenges presented by poverty, competing priorities, unpredictable life events, social identity, gender norms, stigma, and medical pluralism-these influences can make initiating and maintaining ART difficult. Second, the health system is generally seen as punishing and uninviting and this can drive HIV-positive people out of care. Third, long-term engagement and adherence requires adaptation and incorporation of ART into daily life, a process which is facilitated by: inherent self-efficacy, social responsibilities, previous HIV-related illnesses and emotional, practical or financial support. These factors together can lead to a "tipping point", a point in time when patients choose to either engage or disengage from care. HIV-positive people may cycle in and out of these care states in response to fluctuations in influences over time. CONCLUSION This analysis provides a practical theory, arising from thematic synthesis of research, to help understand the dynamics of adherence to ART and engagement in HIV care. This can contribute to the design of service delivery approaches, and informed thinking and action on the part of policy makers, providers, and society: to understand what it is to be HIV-positive in Africa and how attitudes and the health service need to shift to help those with HIV lead 'normal' lives.
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23
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Eshun-Wilson I, Rohwer A, Hendricks L, Oliver S, Garner P. Being HIV positive and staying on antiretroviral therapy in Africa: A qualitative systematic review and theoretical model. PLoS One 2019; 14:e0210408. [PMID: 30629648 PMCID: PMC6328200 DOI: 10.1371/journal.pone.0210408&type=printable] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 12/21/2018] [Indexed: 05/22/2023] Open
Abstract
BACKGROUND Adherence to antiretroviral therapy (ART) and long-term uninterrupted engagement in HIV care is difficult for HIV-positive people, and randomized trials of specific techniques to promote adherence often show small or negligible effects. Understanding what influences decision-making in HIV-positive people in Africa may help researchers and policy makers in the development of broader, more effective interventions and policies. METHODS We used thematic synthesis and a grounded theory approach to generate a detailed narrative and theoretical model reflecting life with HIV in Africa, and how this influences ART adherence and engagement decisions. We included qualitative primary studies that explored perspectives, perceptions and experiences of HIV-positive people, caregivers and healthcare service providers. We searched databases from 1 January 2013 to 9 December 2016, screened all studies, and selected those for inclusion using purposeful sampling methods. Included studies were coded with Atlas.ti, and we assessed methodological quality across five domains. RESULTS We included 59 studies from Africa in the synthesis. Nine themes emerged which we grouped under three main headings. First, people who are HIV-positive live in a complicated world where they must navigate the challenges presented by poverty, competing priorities, unpredictable life events, social identity, gender norms, stigma, and medical pluralism-these influences can make initiating and maintaining ART difficult. Second, the health system is generally seen as punishing and uninviting and this can drive HIV-positive people out of care. Third, long-term engagement and adherence requires adaptation and incorporation of ART into daily life, a process which is facilitated by: inherent self-efficacy, social responsibilities, previous HIV-related illnesses and emotional, practical or financial support. These factors together can lead to a "tipping point", a point in time when patients choose to either engage or disengage from care. HIV-positive people may cycle in and out of these care states in response to fluctuations in influences over time. CONCLUSION This analysis provides a practical theory, arising from thematic synthesis of research, to help understand the dynamics of adherence to ART and engagement in HIV care. This can contribute to the design of service delivery approaches, and informed thinking and action on the part of policy makers, providers, and society: to understand what it is to be HIV-positive in Africa and how attitudes and the health service need to shift to help those with HIV lead 'normal' lives.
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Affiliation(s)
- Ingrid Eshun-Wilson
- Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Department of Medicine, University of California San Francisco, San Francisco, California, United States of America
- * E-mail:
| | - Anke Rohwer
- Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Lynn Hendricks
- Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Sandy Oliver
- UCL Institute of Education, University College London, London, United Kingdom
- Africa Centre for Evidence, University of Johannesburg, Johannesburg, South Africa
| | - Paul Garner
- Centre for Evidence Synthesis in Global Health, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
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24
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Probable antenatal depression at antiretroviral initiation and postpartum viral suppression and engagement in care. AIDS 2018; 32:2827-2833. [PMID: 30234603 DOI: 10.1097/qad.0000000000002025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVE To estimate the association of probable antenatal depression with postpartum HIV care engagement among pregnant women in Malawi. DESIGN We conducted a prospective cohort study of 299 women who were initiating antiretroviral therapy (ART) through Option B+ at a government antenatal clinic in Malawi. METHODS Probable antenatal depression was assessed on the day of ART initiation with the validated Chichewa version of the Edinburgh Postnatal Depression Scale (EPDS). We estimated crude and adjusted risk differences (RD, aRD) of visit attendance and prevalence differences (PD, aPD) of viral suppression through 12 months post-ART initiation comparing women with versus without probable antenatal depression. RESULTS One in 10 women had probable antenatal depression. Most women were engaged in care through 12 months post-ART initiation: 85% attended all scheduled ART visits, and 81% were in care and virally suppressed. Women with and without probable antenatal depression had a comparable probability of attending all scheduled visits (RD: -0.02; 95% CI -0.16 to 0.12; aRD: -0.04; 95% CI -0.18 to 0.10), and of viral suppression (PD: -0.02; 95% CI -0.17 to 0.13; aPD: -0.01; 95% CI -0.17 to 0.15) in crude and adjusted analyses. CONCLUSION Probable antenatal depression was not associated with engagement in HIV care through 12 months post-ART initiation. In a population with high HIV care engagement, antenatal depression may not impair HIV-related outcomes.
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25
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Skovdal M, Maswera R, Kadzura N, Nyamukapa C, Rhead R, Wringe A, Gregson S. Parental obligations, care and HIV treatment: How care for others motivates self-care in Zimbabwe. J Health Psychol 2018; 25:2178-2187. [PMID: 30027764 PMCID: PMC7583436 DOI: 10.1177/1359105318788692] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
This article examines how parental obligations of care intersect with HIV treatment-seeking behaviours and retention. It draws on qualitative data from eastern Zimbabwe, produced from 65 interviews. Drawing on theories of practice and care ethics, our analysis revealed that norms of parental obligation and care acted as key motivators for ongoing engagement with HIV services and treatment. Parents' attentiveness to the future needs of their children (caring about), and sense of obligation (taking care of) and improved ability to care (caregiving) following treatment initiation, emerged as central to understanding their drive for self-care and engagement with HIV services.
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Affiliation(s)
| | | | - Noah Kadzura
- Biomedical Research and Training Institute, Zimbabwe
| | - Constance Nyamukapa
- Biomedical Research and Training Institute, Zimbabwe.,Imperial College London, UK
| | | | | | - Simon Gregson
- Biomedical Research and Training Institute, Zimbabwe.,Imperial College London, UK
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26
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Shabalala FS, Vernooij E, Pell C, Simelane N, Masilela N, Spiegelman D, Chai B, Khan S, Reis R. Understanding reasons for discontinued antiretroviral treatment among clients in test and treat: a qualitative study in Swaziland. J Int AIDS Soc 2018; 21 Suppl 4:e25120. [PMID: 30027651 PMCID: PMC6053483 DOI: 10.1002/jia2.25120] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 05/13/2018] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION Retention on antiretroviral therapy (ART) is critical for the successful adoption of the test and treat policy by sub-Saharan African countries, and for realizing the United Nations programme on HIV and AIDS target of 90-90-90. This qualitative study explores HIV positive clients' reasons for discontinuing ART under the MaxART test and treat implementation study in Swaziland. METHODS Clients identified as lost to follow-up (LTFU) in the programme database, who had initiated ART under the intervention arm of the MaxART study, were purposively selected from two facilities. LTFU was defined as stopping ART refill for three months or longer from the date of last appointment, and not being classified as transferred out or deceased. Semi-structured face-to-face interviews were conducted with nine clients and one treatment supporter between July and August 2017. All interviews were conducted in the local language, audio-recorded, summarized or transcribed and translated to English for thematic analysis. RESULTS Respondents described mobility as the first step in a chain of events that affected retention in care. It was entwined with precarious employment, care delivery, interactions with health workers, lack of social support, anticipated stigma and ART-related side-effects, including the exacerbation of hunger. The chains of events involved several intersecting reasons that occurred one after the other as a series of contiguous and linked events that led to clients' eventual discontinuation of ART. The individual accounts of step-by-step decision-making revealed the influence of multi-layered contexts and the importance of critical life-events. CONCLUSIONS Clients' reasons for abandoning ART are a complex, inextricably interwoven chain of events rather than a single occurrence. Mobility is often the first step in the process and commonly results from precarious economic and social circumstances. Currently the health system poorly caters to the reality of people's mobile lives. Interventions should seek to increase healthcare workers' understanding of the chain of events leading up to discontinuation on ART and the social dilemmas that clients face.
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Affiliation(s)
- Fortunate S Shabalala
- Department of AnthropologyAmsterdam Institute for Social Science ResearchUniversity of AmsterdamAmsterdamthe Netherlands
- Department of Community Health Nursing SciencesFaculty of Health SciencesUniversity of SwazilandMbabaneSwaziland
| | - Eva Vernooij
- Department of AnthropologyAmsterdam Institute for Social Science ResearchUniversity of AmsterdamAmsterdamthe Netherlands
- Department of Social AnthropologySchool of Social and Political ScienceUniversity of EdinburghEdinburghUK
| | - Christopher Pell
- Department of AnthropologyAmsterdam Institute for Social Science ResearchUniversity of AmsterdamAmsterdamthe Netherlands
- Amsterdam Institute for Global Health and DevelopmentAmsterdamthe Netherlands
| | - Njabulo Simelane
- Department of AnthropologyAmsterdam Institute for Social Science ResearchUniversity of AmsterdamAmsterdamthe Netherlands
| | - Nelisiwe Masilela
- Department of AnthropologyAmsterdam Institute for Social Science ResearchUniversity of AmsterdamAmsterdamthe Netherlands
| | | | - Boyang Chai
- Harvard T.H. Chan School of Public HealthBostonMAUSA
| | - Shaukat Khan
- Clinton Health Access Initiative (CHAI)MbabaneSwaziland
| | - Ria Reis
- Department of AnthropologyAmsterdam Institute for Social Science ResearchUniversity of AmsterdamAmsterdamthe Netherlands
- Department of Public Health and Primary CareLeiden University Medical CentreLeidenthe Netherlands
- The Children's InstituteSchool of Child and Adolescent HealthUniversity of Cape TownCape TownSouth Africa
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27
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Camlin CS, Cassels S, Seeley J. Bringing population mobility into focus to achieve HIV prevention goals. J Int AIDS Soc 2018; 21 Suppl 4:e25136. [PMID: 30027588 PMCID: PMC6053544 DOI: 10.1002/jia2.25136] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 05/22/2018] [Indexed: 11/08/2022] Open
Affiliation(s)
- Carol S Camlin
- Department of Obstetrics, Gynecology and Reproductive SciencesDepartment of MedicineUniversity of CaliforniaSan FranciscoUSA
| | - Susan Cassels
- Department of GeographyUniversity of CaliforniaSanta BarbaraUSA
| | - Janet Seeley
- Department of Global Health and DevelopmentLondon School of Hygiene and Tropical MedicineLondonUK
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28
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Wringe A, Renju J, Seeley J, Moshabela M, Skovdal M. Bottlenecks to HIV care and treatment in sub-Saharan Africa: a multi-country qualitative study. Sex Transm Infect 2018; 93:sextrans-2017-053172. [PMID: 28736397 PMCID: PMC5739850 DOI: 10.1136/sextrans-2017-053172] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 05/20/2017] [Indexed: 11/30/2022] Open
Affiliation(s)
- Alison Wringe
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Jenny Renju
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Janet Seeley
- Medical Research Council/Uganda Virus Research Institute Research Unit on AIDS, Entebbe, Uganda.,Department of Global Health, London School of Hygiene and Tropical Medicine, London, UK.,Africa Health Research Institute, KwaZulu Natal, South Africa
| | - Mosa Moshabela
- Africa Health Research Institute, KwaZulu Natal, South Africa.,University of KwaZulu Natal, Durban, South Africa
| | - Morten Skovdal
- University of Copenhagen, Copenhagen, Denmark.,Biomedical Research and Training Institute, Harare, Zimbabwe
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