The first decade of antiretroviral therapy in Africa

Unpacking the process of developing South Africa's national drug policy - lessons for universal health coverage

Background

South Africa's National Drug Policy (NDP) was first issued in 1996, at a time of considerable political change.

Objectives

To revisit the lessons learned from the process of development and initial implementation of the NDP.

Methods

Six in-depth face-to-face interviews were held with purposively-selected key actors. Interviews, which followed pre-determined semi-structured questions, but were allowed to explore additional areas, were recorded and transcribed, and then subjected to abductive thematic analysis, informed by the Walt and Gilson model.

Results

Three key themes emerged, described as 'evidence', 'trust' and 'looking forward'. A paucity of evidence backed some of the key concepts in the NDP, and these have not been addressed as evidence has matured. The lack of trust which characterised the policy process impacted on the ways in which actors were able to or not able to engage, and therefore on the resultant content and the choices exercised. The coherence of the policy, its articulation with other health reforms, and its contribution to subsequent efforts to ensure universal health coverage in South Africa have all been weakened by the failure to revise the document over time.

Conclusion

As South Africa advances its plans for universal health coverage, there is an urgent need to revisit key components of the NDP which are no longer fit for purpose.

Moving towards a person-centred HIV care cascade: An exploration of potential biases and errors in routine data in South Africa

In 2022, in recognition of lags in data infrastructure, the World Health Organisation (WHO) recommended the use of routinely linked individual patient data to monitor HIV programmes. The WHO also recommended a move to person-centred care to better reflect the experiences of people living with HIV. The switch from aggregated service level data to person-centred data will likely introduce some biases and errors. However, little is understood about the direction and magnitude of these biases. We investigated HIV-testing and HIV-care engagement from 2014 to 2018 in the Agincourt Health and Demographic Surveillance System (HDSS). We digitised and linked HIV patient clinic records to HDSS population data in order to estimate biases in routine clinical data. Using this linked data, we followed all individuals linked to HIV-related clinic data throughout their care pathway. We built sequences to represent these pathways. We performed sequence and cluster analyses for all individuals to categorise patterns of care engagement and identified factors associated with different engagement patterns using multinomial logistic regression. Our analyses included 4947 individuals who were linked to 5084 different patient records. We found that routine data would have inflated patient numbers by 2% due to double counting. We also found that 2% of individuals included in our analyses had received multiple HIV tests. These phenomena were driven by undocumented transfers. Further analysis of engagement patterns found a low level of stable engagement in care (<33%). Engagement fell into three distinct clusters: (i) characterised by high rates of late ART initiation, unstable engagement in care, and high mortality (53.9%), (ii) characterised by early ART initiation followed by prolonged periods of LTFU (13.7%), and (iii) characterised by early ART initiation followed by stable engagement in care (32.4%). Compared to cluster (i) older individuals were less likely to be in cluster (ii) and more likely to be in cluster (iii). Those who initiated ART prior to 2016 were more likely to be in cluster (ii) and (iii) compared to cluster (i). Those who initiated ART for PMTCT (RRR: 1.88 (95% CI: 1.45, 2.44)) or TB coinfection (RRR: 2.11 (95% CI: 1.27, 3.50)) were more likely to be in cluster (ii) when compared to those who initiated ART due to CD4 eligibility criteria. Males (RRR: 0.63 (95% CI: 0.51, 0.77)) were less likely to be in cluster (iii) compared to cluster (i) as were those who initiated ART for PMTCT (RRR: 0.77 (95% CI: 0.62, 0.97)) or under test and treat guidelines when compared to those who initiated ART due to CD4 eligibility. Only a minority of patients are consistently engaged in care while the majority cycle between engagement and disengagement. Individual level data could be useful in monitoring programmes and accurately reporting patient figures if it is of high quality, has minimal missingness and is properly linked in order to account for biases that accrue from using this kind of data.

In utero/peripartum antiretroviral therapy exposure and mental health outcomes at 8-18 years old: A longitudinal comparative study of children with perinatally acquired HIV, children perinatally HIV exposed but uninfected, and children unexposed uninfected from Uganda

In utero/peripartum antiretroviral therapy (IPA) exposure type was examined in relationship to mental health symptoms among 577 children with perinatally acquired HIV (CPHIV), children perinatally HIV exposed but uninfected (CHEU), and children HIV unexposed uninfected (CHUU). IPA exposure was categorized for CPHIV and CHEU as none, single-dose nevirapine with or without zidovudine (sdNVP±AZT), sdNVP+AZT+lamivudine (3TC), or combination antiretroviral therapy (cART). Anxiety and depressive symptoms were reported at baseline, 6-, and 12-month follow-up per behavioral assessment system for children. Multivariable linear mixed models were used to estimate differences (b) with 95% confidence intervals (95% CI) for IPA exposure types versus CHEU without IPA exposure. Depressive and anxiety symptoms were lower in CHUU relative to CHEU and CPHIV but did not differ between CPHIV and CHEU. CHEU with sdNVP±AZT exposure had greater anxiety (b = 0.51, 95% CI: [0.06, 0.96]) and depressive symptoms (b = 0.48, 95% CI: [0.07, 0.89]) than CHEU without IPA exposure. CHEU with sdNVP+AZT+3TC exposure had higher anxiety (b = 0.0.45, 95% CI: [0.03, 0.86]) and depressive symptoms (b = 0.72, 95% CI: [0.27, 1.17]) versus CHEU without IPA exposure. Depressive and anxiety symptoms were not different for CHEU and CPHIV exposed to cART (b = 0.12-0.60, 95% CI: [-0.41, 1.30]) and CHEU and CHUU (b = -0.04 to 0.08, 95% CI: [-0.24, 0.29]) without IPA exposure. Among CHEU, peripartum sdNVP±AZT and sdNVP+AZT+3TC but not cART compared to no IPA exposure was associated with clinically important elevations in anxiety and depressive symptoms. Monitoring of mental health trajectory of HIV-affected children considering IPA is needed to inform mental health interventions. Patient Contribution: Caregivers and their dependents provided consent for participation and collaborated with study team to identify mutually convenient times for protocol implementation.

Understanding the role of religious beliefs in adherence to antiretroviral therapy among Pentecostal Christians living with HIV in sub-Saharan Africa: a scoping review

BACKGROUND

Optimum adherence to antiretroviral therapy (ART) is crucial in managing HIV. However, some people's religious beliefs can influence how they deal with HIV and the psychosocial factors influencing their adherence to ART, such as disclosure, acceptance of HIV status, belief in ART, and depression. In sub-Saharan Africa (SSA), the role of religious beliefs in ART adherence is underexplored. We aimed to identify and conceptualize the literature on religious beliefs concerning ART adherence among Pentecostal Christians living with HIV in SSA.

METHODS

We conducted a scoping review of the literature on religious beliefs and ART adherence. We searched papers from PubMed, Web of Science, Medline, Sabinet, Academic Search Complete, CINAHL Plus, Health Source/Nursing Academic, Scopus, and Google Scholar and published papers from conference proceedings and dissertations. Data were extracted according to a predetermined population, concept, context framework, and eligibility criteria for selecting or rejecting studies. We used a narrative synthesis to summarize the data on evidence and the impact of religious beliefs on ART adherence.

RESULTS

Seven papers published between January 2010 and February 2022 met the inclusion criteria. Nineteen aspects of religious beliefs were identified as negatively influencing ART adherence, while eight aspects facilitated optimal adherence. "Being saved" or "born again" enhanced coping strategies for optimal adherence through actions such as less alcohol use, fidelity to a sexual partner(s), disclosure, acceptance of HIV status, reduced depression, and facilitated PLHIV to access social support from church members or other institutions.

CONCLUSION

Religious beliefs are integral to Pentecostal Christians living with HIV and affect their adherence to ART. While some Pentecostal Christians living with HIV on ART use their religious beliefs and practices to access psychosocial support from other church members or organizations and achieve good clinical outcomes, others apply their religious beliefs and practices differently and compromise their commitments to taking ART as prescribed, thus experiencing poor viral suppression and clinical outcomes. However, more research is required to understand and theorize how religious beliefs impact ART adherence among Pentecostals living with HIV to inform guidelines for practitioners.

Opioid use and HIV treatment services experiences among male criminal justice-involved persons in South Africa: a qualitative study

BACKGROUND

Opioid use disorder (OUD) is overrepresented among people with criminal justice involvement; HIV is a common comorbidity in this population. This study aimed to examine how formerly incarcerated men living with HIV and OUD in South Africa experienced HIV and OUD services in correctional facilities and the community.

METHODS

Three focus group discussions were conducted with 16 formerly incarcerated men living with HIV and OUD in Gauteng, South Africa. Discussions explored available healthcare services in correctional facilities and the community and procedural and practice differences in health care between the two types of settings. Data were analyzed thematically, using a comparative lens to explore the relationships between themes.

RESULTS

Participants described an absence of medical services for OUD in correctional facilities and the harms caused by opioid withdrawal without medical support during incarceration. They reported that there were limited OUD services in the community and that what was available was not connected with public HIV clinics. Participants perceived correctional and community HIV care systems as readily accessible but suggested that a formal system did not exist to ensure care continuity post-release.

CONCLUSIONS

OUD was perceived to be medically unaddressed in correctional facilities and marginally attended to in the community. In contrast, HIV treatment was widely available within the two settings. The current model of OUD care in South Africa leaves many of the needs of re-entrants unmet. Integrating harm reduction into all primary care medical services may address some of these needs. Successful HIV care models provide examples of approaches that can be applied to developing and expanding OUD services in South Africa.

Association between mental disorders and adherence to antiretroviral treatment in health facilities in two Mozambican provinces in 2018: a cross-sectional study

INTRODUCTION

Lower adherence to antiretroviral treatment (ART) has been found among people with HIV (PWH) who have comorbid mental disorders like depression and alcohol use in Sub-Saharan African. However, there has been less exploration with regards to other mental disorders.

METHODS

This study assessed the association of multiple mental disorders and adherence to ART based on the data from primary/tertiary health care facilities in Maputo and Nampula, Mozambique. We administered a sociodemographic questionnaire, Mini International Neuropsychiatric Interview (MINI) Plus 4.0.0 adapted for use in Mozambique to assess mental conditions, and a 3-item self-report to measure ART adherence.

RESULTS

395 HIV-positive (self-report) participants on ART, with an average age of 36.7 years (SD = 9.8), and 30.4% were male. The most common mental disorders were major depressive disorder (27.34%) followed by psychosis (22.03%), suicidal ideation/behavior (15.44%), and alcohol-use disorder (8.35%). Higher odds of missing at least one dose in the last 30 days (OR = 1.45, 95% CI: 1.01, 2.10) were found in participants with any mental disorder compared to those without a mental disorder. The highest levels of non-adherence were observed among those with drug use disorders and panic disorder.

CONCLUSIONS

In Mozambique, PWH with any co-occurring mental conditions had a lower probability of ART adherence. Integrating comprehensive mental health assessment and treatment and ART adherence interventions tailored to PWH with co-occurring mental disorders is necessary to attain optimal ART adherence and reach the UNAIDS ART target.

Mode of HIV acquisition among adolescents living with HIV in resource-limited settings: A data-driven approach from South Africa

Adolescents living with HIV (ALHIV) face unique treatment and care challenges which may differ by how they acquired HIV, whether vertically (in-utero, perinatal or postnatal exposure during breastfeeding) or sexually (sexual exposure). Distinguishing and documenting the mode of HIV acquisition (MOHA) is crucial to further research on the different needs and outcomes for ALHIV and to tailor HIV services to their needs. Age-based cut-offs have been used to attribute MOHA but have not been validated. We analysed data from a three-wave cohort of n = 1107 ALHIV part of a longitudinal study in South Africa. Age-based MOHA was allocated using age at ART initiation, validated against a logic-tree model based on literature-hypothesised factors: self-reported HIV, sexual, and family history. After testing six ART initiation age cut-offs (10 to 15 years old), we determined the optimal MOHA cut-off age by calculating the sensitivity and specificity for each cut-off, measured against the final logic-tree allocation. Following validation using this longitudinal study, the methodology is extended to 214 additional third-wave participants-adolescent girls and young women living with HIV who became mothers before the age of 20. Finally, descriptive statistics of the final allocations are presented. Among the 1,063 (96.0%) cohort study participants classified, 68.7% acquired HIV vertically, following validation. ART initiation before cut-off age 10 had the highest sensitivity (58.9%) but cut-off age 12 had the largest area under the curve (AUC) (0.712). Among the additional young mothers living with HIV, 95.3% were estimated to have acquired it sexually, following the same algorithm. For this group, while cut-off ages 10 to 12 had the highest sensitivity (92.2%), age 14 had the highest AUC (0.703). ART initiation before 10 years old is strongly associated with vertical HIV acquisition. Therefore, a cut-off age of 10 would remain the recommendation in LMIC regions with similar epidemiology as South Africa for determining MOHA in research and clinic settings.

The Role of Civil Society in Mobilizing Human Rights Struggles for Essential Medicines: A Critique from HIV/AIDS to COVID-19

In this paper, we explore the strategies utilized by civil society organizations to improve access to medicines during the HIV/AIDS and COVID-19 health crises. In particular, we seek to illuminate why some of the successful approaches for increasing access to antiretrovirals for HIV/AIDS in the early 2000s failed in creating equitable global access to COVID-19 vaccines. While civil society has historically mobilized human rights to facilitate greater access to essential medicines, we argue that earlier strategies were not always sustainable and that civil society is now mobilizing human rights in radically different ways than previously. Instead of focusing chiefly on securing an intellectual property waiver to the TRIPS Agreement, civil society organizations are now challenging vaccine injustice, rejecting the "charity discourse" that fuels Global South dependency on Global North actors in favor of scaling up manufacture in low- and middle-income countries, and moving to embed the right to access medicines in a new World Health Organization pandemic treaty with civil society organization participation and meaningful representation from low- and middle-income countries. Such approaches, we contend, will lead to more sustainable solutions in order to avert further health care disasters, like those seen with two distinct but related struggles-the fights for equitable access to essential medicines for HIV/AIDS and for COVID-19.

Antiretroviral therapy and aging as resources for managing and resisting HIV-related stigma in rural South Africa

The widespread roll-out of antiretroviral therapy (ART) in Africa has contributed to a large population of adults aging with HIV. However, little is known about how HIV-related stigma interacts with aging in the ART era. This study uses in-depth interviews with middle-aged and older South Africans living with HIV to explore stigma-related experiences and response strategies. Participants describe a persistence of stigma which requires the deployment of a range of common and age-based stigma management and resistance strategies. We find that participants minimize their exposure to stigma through selective disclosure of their HIV status; neutralize HIV-related stigma through comparisons to chronic illnesses common among older adults, and deflect stigma through asserting an ART-adherent identity and othering younger non-adherent adults. Overall, our study highlights the roles of ART and aging as resources for managing and resisting HIV-related stigma.

Challenges in the management of inflammatory bowel disease in sub-Saharan Africa

Inflammatory bowel disease (IBD) is generally considered a disease of high-income countries and is regarded as rare in sub-Saharan Africa. However, this assumption is almost certainly an underestimate, and the high burden of communicable diseases makes IBD in sub-Saharan Africa difficult to detect. Furthermore, some gastrointestinal infections can closely mimic IBD, contributing to delays in diagnosis and complicating therapeutic decision making. Constraints in endoscopic capacity alongside a scarcity of qualified diagnostic pathologists add to the difficulties. Implementing evidence-based guidelines recommended by international societies is challenging, mostly due to high costs and unavailability of medication. However, cost-effective approaches can still be implemented to manage IBD in sub-Saharan Africa as the predominant disease phenotype is mild-to-moderate ulcerative colitis, which often responds to treatment with basic medication. In this Series paper, we summarise the current management of IBD in sub-Saharan Africa and propose how it can be tailored to suit the epidemiological and socioeconomic specificities of the region. We also discuss measures required to address existing challenges, such as educating health-care workers about the diagnosis and management of IBD or improving endoscopic capacity.

Evaluation of four chemotherapy regimens for treatment of advanced AIDS-associated Kaposi sarcoma in Kenya: a cost-effectiveness analysis

BACKGROUND

The most effective treatment for advanced AIDS-associated Kaposi sarcoma is paclitaxel or pegylated liposomal doxorubicin (PLD); neither is routinely used in sub-Saharan Africa due to limited availability and high cost. We examined the clinical impact, costs, and cost-effectiveness of paclitaxel or PLD in Kenya, compared with etoposide or bleomycin-vincristine.

METHODS

In this study, we use the Cost-Effectiveness of Preventing AIDS Complications (CEPAC)-International Model to project clinical outcomes and costs among people living with HIV and advanced Kaposi sarcoma on antiretroviral therapy. We compared four different treatment strategies: etoposide, bleomycin-vincristine, paclitaxel, or PLD. We derived cohort characteristics and costs from the Kenyan Academic Model for Providing Access to Healthcare network, and adverse events, efficacy, and mortality from clinical trials. We projected model outcomes over a lifetime and included life expectancy, per-person lifetime costs, and incremental cost-effectiveness ratios (ICERs). We conducted budget impact analysis for 5-year total costs and did deterministic and probabilistic sensitivity analyses to evaluate the effect of uncertainty in input parameters.

FINDINGS

We found that paclitaxel would be more effective than bleomycin-vincristine and would increase life expectancy by 4·2 years per person. PLD would further increase life expectancy by 0·6 years per person. Paclitaxel would be the most cost-effective strategy (ICER US$380 per year-of-life-saved compared with bleomycin-vincristine) and would remain cost-effective across a range of scenarios. PLD would be cost-effective compared with paclitaxel if its price were reduced to $100 per cycle (base case $180 per cycle). Implementing paclitaxel instead of bleomycin-vincristine would save approximately 6400 life-years and would increase the overall 5-year Kenyan health-care costs by $3·7 million; increased costs would be primarily related to ongoing HIV care given improved survival.

INTERPRETATION

Paclitaxel would substantially increase life expectancy and be cost-effective compared with bleomycin-vincristine for advanced AIDS-associated Kaposi sarcoma in Kenya and should be the standard of care. PLD would further improve survival and be cost-effective with a 44% price reduction.

FUNDING

US National Institutes of Health and Massachusetts General Hospital.

TRANSLATION

For the Swahili translation of the abstract see Supplementary Materials section.

Emergence of universal antiretroviral therapy coverage in South Africa: applying the advocacy coalition framework to refine the narratives and inform epidemic responses

South Africa possesses the largest anti-retroviral therapy (ART) program in the world, but the path to this record was dramatic. There is scarce literature employing a comprehensive framework to explain this achievement and inform epidemic responses. This paper applies the Advocacy Coalition Framework (ACF) to analyse the interactions among diverse actors, institutions and networks that were associated with the AIDS policy change in South Africa. Post-apartheid, HIV/AIDS and AIDS-related mortality were serious public health problems. At the time, the discernible coalitions in the HIV/AIDS policy subsystem were the pro-science coalition and AIDS dissidents. In view of the availability of compelling scientific evidence on the pathogenesis of HIV/AIDS, the clinical usefulness of ART, the availability of funding for national ART roll-out, strong global advocacy to reduce the cost of ART, all of these in an era when access to adequate HIV treatment/care was increasingly considered a human right, the environment to establish an appropriate HIV/AIDS policy for the country was conducive. However, AIDS dissidents dominated the policy agenda via their control over key institutions, the use of various dimensions of power, biasing evidence to inform policy, and promoting the activities of strong interest groups that were not in support of ART. National ART roll-out finally emerged as a political priority because of external shocks (on the AIDS policy subsystem) which disfavoured the dominant coalition. As in this important experience in the history of HIV treatment, stakeholders involved in epidemic response tend to engage in intense ideological conflicts. An adequate appraisal of the outcomes of these conflicts in terms of population health gains and adopted public health and social measures to control epidemics would require the supplementation of complex system thinking with relevant public policy concepts, notably power dimensions, governance, emergence of global health networks and evidence use in policy.

A Case Report of Multiclass HIV Drug-Resistance After an Inappropriate Switch of ARVs with Persistent Unsuppressed Viral Load

HIV drug resistance is an emerging public health concern; appropriate ART combinations and safe drug switches are prerequisites for achieving virologic suppression. In the early 2000, in Sub-Saharan Africa, accent was mostly on prevention and the scale up of Antiretroviral therapy has just initiated. We report a 46-year-old female who was initiated on ART in 2005 in the private sector, had multiple regimens changes for unclear reasons. Over 7 years (2005-2012), she deteriorated and presented with an AIDS defining condition. A genotyping resistance test (GRT) revealed multiple HIV class resistance and was switched to a third-line ART and improved on treatment. This case report shows that the absence of formal ART guidelines in early 2000, long term exposure to ART and failure to timely switch led to treatment failure and development of multiclass drug resistance mutations identified by the HIV-1 GRT and guided the third-line ART regimen with a successful outcome.

Perceived satisfaction with HIV care and its association with adherence to antiretroviral therapy and viral suppression in the African Cohort Study

Background

Increased availability of HIV care over the past decade has dramatically reduced morbidity and mortality among people living with HIV (PLWH) in sub-Saharan Africa. However, perceived and experienced barriers to care, including dissatisfaction with services, may impact adherence and viral suppression. We examined the associations between satisfaction with HIV care and antiretroviral therapy (ART) adherence and viral load suppression.

Methods

The African Cohort Study (AFRICOS) is a prospective observational study conducted at PEPFAR-supported clinics in four African countries. At enrollment and twice-yearly study visits, participants received a clinical assessment and a socio-behavioral questionnaire was administered. Participants were classified as dissatisfied with care if they reported dissatisfaction with any of the following: waiting time, health care worker skills, health care worker attitudes, quality of clinic building, or overall quality of care received. Robust Poisson regression was used to estimate prevalence ratios and 95% confidence intervals (CIs) for associations between satisfaction with care and ART adherence and between satisfaction with care and viral suppression (viral load < 1000 copies/mL).

Results

As of 1 March 2020, 2928 PLWH were enrolled and 2311 had a year of follow-up visits. At the first annual follow-up visit, 2309 participants responded to questions regarding satisfaction with quality of care, and 2069 (89.6%) reported satisfaction with care. Dissatisfaction with waiting time was reported by 177 (7.6%), building quality by 59 (2.6%), overall quality of care by 18 (0.8%), health care worker attitudes by 16 (0.7%), and health care worker skills by 15 (0.7%). After adjusting for age and site, there was no significant difference in viral suppression between those who were satisfied with care and those who were dissatisfied (aPR: 1.03, 95% CI 0.97–1.09). Satisfaction with HIV care was moderately associated with ART adherence among AFRICOS participants (aPR: 1.09; 95% CI 1.00–1.16).

Conclusions

While patient satisfaction in AFRICOS was high and the association between perceived quality of care and adherence to ART was marginal, we did identify potential target areas for HIV care improvement, including reducing clinic waiting times.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12981-021-00414-3.

Global Knowledge Gaps in Equitable Delivery of Chronic Edema Care: A Political Economy Case Study Analysis

Background: Most existing research in chronic edema (CO) care takes place in high-income countries and is both clinically and medically focused, although often accorded low prestige and status. A myriad of challenges define the problems and important gaps in understanding and translating what we know into sustainable practice. Less considered, however, are the consequences and socioeconomic significance of this "knowledge gap" in an increasingly globalized world. This article seeks to address this lacuna by suggesting a political economy approach across three different income settings, the United Kingdom (high), Kerala in India (middle), and Uganda (low), to learn from international practice and understand the contribution of local (community-specific) health traditions. Methods and Result: We used a comparative case study approach. In the three case studies we demonstrate how particular thinking, sets of power relationships, and resource distributions influence and structure the provision of CO management more generally. We demonstrate how these intertwined and often invisible processes reflect a market-led biomedical hierarchization that focuses on high-interventionist, high-cost approaches that are then imposed on lower income settings. At the same time, low-cost but evidence-based local knowledge innovation in wound and CO care from low- or middle-income countries is neither recognized nor valued. Conclusion: We conclude that unpacking these dynamics is a necessary route to providing a more equitable health delivery accessible for the many rather than the few.

Priorities for global access to life-saving interventions during public health emergencies: Crisis nationalism, solidarity or charity?

Access to COVID-19-vaccines by the global poor has unveiled the impact of global health and scientific inequities on access to life saving interventions during public health emergencies (PHE). Despite calls for global solidarity to ensure equitable global access to COVID-19 vaccines, wealthy countries both in the north and southern hemisphere may find a charity-based approach more appealing and are using the opportunity to forge neo-colonial cooperation ties with some African countries. Solidarity is undoubtedly an ideal equity-based principle of public health emergency of international concern (PHEIC). However, its application may be wanting especially as crisis nationalism is more likely to inform the public health policy of any country during a PHEIC, even when they are strong advocates of global solidarity. African countries, on the other hand, must re-appraise their heavy reliance on international aids during PHE and recognise the importance of boosting their epidemic preparedness including research and translation of its findings to practice.

New Directions for the Consideration of HIV: Heterogeneity and the Cognition of Time

It has been almost 40 years since HIV emerged in the human population with an alarming impact in 1981, quickly reaching pandemic proportions. Reaching the goal of eradication, or at least ending the pandemic, however, has not been as easy as hoped. To better understand and therefore better address the persistence and often devastating effects of this now chronic disease, the heterogeneity of HIV-in the virus-human and human-human relationships it engages-is parsed in discussions of the groups affected and the multiple factors that drive the diverse effects of the disease, both of which make treatment and prevention of the disease highly challenging. The construct of time cognition is then considered as a heretofore unexplored factor that may inform our understanding of HIV-relevant behaviors.

Demographic trends in less and least developed countries: Convergence or divergence?

Many scholars share the assumption that demographic patterns in the world are converging over time. The present study analyses the temporal trends of specific parameters of mortality and fertility—together with certain socio-economic indicators—in 95 less and least developed countries during the period 1990–2015 and discusses whether mortality and fertility trends are convergent or divergent. We apply dynamic factor analysis and cluster analysis of trajectories to macro-data from major international sources. The results show that a large number of countries have a convergent trend in mortality, but sub-Saharan African countries affected by the HIV–AIDS epidemic show non-monotonic temporal trends. Trends in fertility are delayed and unclear and depend on individual attitudes and levels of women’s empowerment. Fifty-two out of the 95 observed countries are collocated in similar mortality and fertility groups. Finally, countries at an advanced economic stage made the best improvements, while the least developed ones retained their deep pre-existing inequalities.

We Cannot Win the Access to Medicines Struggle Using the Same Thinking That Causes the Chronic Access Crisis

The inequity in access to COVID-19 vaccines that we are witnessing today is yet another symptom of a pharmaceutical economy that is not fit for purpose. That it was possible to develop multiple COVID-19 vaccines in less than a year, while at the same time fostering extreme inequities, calls for transformative change in the health innovation and access ecosystem. Brought into the spotlight through the AIDS drugs access crisis, challenges in accessing lifesaving medicines and vaccines-because they are either not available or inaccessible due to excessive pricing-are being faced by people all over the world. To appreciate the underlying framing of current access discussions, it is important to understand past trends in global health policies and the thinking behind the institutions and mechanisms that were designed to solve access problems. Contrary to what might be expected, certain types of solutions intrinsically carry the conditions that enable scarcity, rationing, and inequity, and lead us away from ensuring the right to health. Analyzing the root causes of access problems and the political economy that allows them to persist and even become exacerbated is necessary to fix access inequities today and to design better solutions to ensure equitable access to health technologies in the future.

Human immunodeficiency virus case detection and antiretroviral therapy enrollment among children below and above 18 months old: A comparative analysis from Cameroon

ABSTRACT

While pediatric human immunodeficiency virus (HIV) testing has been more focused on children below 18 months through prevention of mother to child transmission of HIV (PMTCT), the yield of this approach remains unclear comparatively to testing children above 18 months through routine provider-initiated testing and counselling (PITC). This study aimed at assessing and comparing the HIV case detection and antiretroviral therapy (ART) enrolment among children below and above 18 months of age in Cameroon. This information is required to guide the investments in HIV testing among children and adolescents.We conducted a cross-sectional study where we invited parents visiting or receiving HIV care in 3 hospitals to have their children tested for HIV. HIV testing was done using polymerase chain reaction (PCR) and antibody rapid tests for children <18 months and those ≥18 months, respectively. We compared HIV case detection and ART initiation between the 2 subgroups of children and this using Chi-square test at 5% significant level.A total of 4079 children aged 6 weeks to 15 years were included in the analysis. Compared with children <18 months, children group ≥18 months was 4-fold higher among those who enrolled in the study (80.3% vs 19.7%, P < .001); 3.5-fold higher among those who tested for HIV (77.6% vs 22.4%, P < .001); 6-fold higher among those who tested HIV+ (85.7% vs 14.3%, P = .24), and 11-fold higher among those who enrolled on ART (91.7% vs 8.3%, P = .02).Our results show that 4 out of 5 children who tested HIV+ and over 90% of ART enrolled cases were children ≥18 months. Thus, while rolling out PCR HIV testing technology for neonates and infants, committing adequate and proportionate resources in antibody rapid testing for older children is a sine quo none condition to achieve an acquired immunodeficiency syndrome (AIDS)-free generation.

COVID/HIV Co-Infection: A Syndemic Perspective on What to Ask and How to Answer

The present commentary explored the intersecting nature of the COVID-19 and HIV pandemics to identify a shared research agenda using a syndemic approach. The research agenda posits the following questions. Questions around HIV infection, transmission, and diagnosis include: (i) molecular, genetic, clinical, and environmental assessments of COVID-19 in people living with HIV, (ii) alternative options for facility-based HIV testing services such as self- and home-based HIV testing, and (iii) COVID-19 related sexual violence and mental health on HIV transmission and early diagnosis. These and related questions could be assessed using Biopsychosocial and socio-ecological models. Questions around HIV treatment include: (i) the effect of COVID-19 on HIV treatment services, (ii) alternative options for facility-based treatment provision such as community-based antiretroviral therapy groups, and (iii) equitable distribution of treatment and vaccines for COVID-19, if successful. Bickman's logic model and the social determinants of health framework could guide these issues. The impact of stigma, the role of leveraging lessons on sustained intra-behavioral change, the role of medical mistrust and conspiracy beliefs, and the role of digital health on integrated management of HIV care and spectrum of care of COVID-19 need assessment using several frameworks including Goffman's stigma framework, Luhmann's Trust theory, and Gidden's theory of structuration. In conclusion, the potential research agenda of this commentary encompasses a variety of research fields and disciplinary areas-clinicians, laboratory scientists, public health practitioners, health economists, and psychologists-, and suggests several theoretical frameworks to guide examination of complex issues comprehensively.

Promoting Undetectable Equals Untransmittable in Sub-Saharan Africa: Implication for Clinical Practice and ART Adherence

In the last decade, reliable scientific evidence has emerged to support the concept that undetectable viral loads prevent human immunodeficiency virus (HIV). Undetectable equals untransmissible (U = U) is a simple message that everyone can understand. The success of this concept depends on strict adherence to antiretroviral therapy (ART) and the attainment of suppressed viral loads (VLs). To achieve U = U in sub-Saharan Africa (SSA), poor adherence to ART, persistent low-level viremia, and the emergence of drug-resistant mutants are challenges that cannot be overlooked. Short of a cure for HIV, U = U can substantially reduce the burden and change the landscape of HIV epidemiology on the continent. From a public health perspective, the U = U concept will reduce stigmatization in persons living with HIV (PLWHIV) in SSA and strengthen public opinion to accept that HIV infection is not a death sentence. This will also promote ART adherence because PLWHIV will aim to achieve U = U within the shortest possible time. This article highlights challenges and barriers to achieving U = U and suggests how to promote the concept to make it beneficial and applicable in SSA. This concept, if expertly packaged by policy-makers, clinicians, health service providers, and HIV control programs, will help to stem the tide of the epidemic in SSA.

Scaling-up PrEP Delivery in Sub-Saharan Africa: What Can We Learn from the Scale-up of ART?

Purpose of Review

Clinical trials have found that PrEP is highly effective in reducing risk of HIV acquisition across types of exposure, gender, PrEP regimens, and dosing schemes. Evidence is urgently needed to inform scale-up of PrEP to meet the ambitious WHO/UNAIDS prevention target of 3,000,000 individuals on PrEP by 2020.

Recent Findings

Successful models of delivering HIV services at scale evolved from years of formal research and programmatic evidence. These efforts produced lessons-learned relevant for scaling-up PrEP delivery, including the importance of streamlining laboratory tests, expanding prescription and management authority, differentiating medication access points, and reducing stigma and barriers of parental consent for PrEP uptake. Further research is especially needed in areas differentiating PrEP from ART delivery, including repeat HIV testing to ensure HIV negative status and defining and measuring prevention-effective adherence.

Summary

Evidence from 15 years of ART scale-up could immediately inform a public health approach to PrEP delivery.

Status and associated factors of self-management in people living with HIV/AIDS in Liangshan area, China: a cross-sectional study

Background: HIV self-management is a lifetime and central task for people living with HIV/AIDS (PLWH). To date, there is little evidence to identify the related factors of self-management in PLWH from China. Purpose: This study aimed to investigate the status and related factors of self-management in PLWH from the Liangshan area of Sichuan Province, China. Patients and methods: A total of 322 PLWH were recruited from August to December 2017 in the study. Demographics characteristics and disease-related data were documented for each participant, social support was measured by the Medical Outcomes Study Social Support Survey (MOS-SSS-C), and self-management was evaluated by the HIV Self-Management Scale. Descriptive statistics analysis, independent Student's t-test, one-way ANOVA, Spearman rank correlation, and multiple regression analysis were used to analyze the data. Results: The total score of HIV self-management was 38.26±7.17. Significant differences in self-management scores were found among the subgroups of different education level, marital status, nation, religion, resident place, occupation, infection route, symptom, research site, and household per capita monthly income. Self-management was positively significantly correlated with social support. Multiple regression analysis identified that nation, resident place, gender, marital status, and social support were the contributors of HIV self-management. Conclusion: The study demostrated that self-management in Yi Autonomous Prefecture was relatively low. The results indicate that the associated factors of self-management should be considered to develop effective intervention to improve the self-management of PLWH.

Community-Based Accompaniment and the Impact of Distance for HIV Patients Newly Initiated on Antiretroviral Therapy: Early Outcomes and Clinic Visit Adherence in Rural Rwanda

Community-based accompaniment (CBA) has been associated with improved antiretroviral therapy (ART) patient outcomes in Rwanda. In contrast, distance has generally been associated with poor outcomes. However, impact of distance on outcomes under the CBA model is unknown. This retrospective cohort study included 537 adults initiated on ART in 2012 in two rural districts in Rwanda. The primary outcomes at 6 months after ART initiation included overall program status, missed a visit and missed three consecutive visits. The associations between cost surface distance (straight-line distance adjusted for surface features) and outcomes were assessed using logistic regression, controlling for potential confounders. Died/lost-to-follow-up and missed three consecutive visits were not associated with distance. Patients within 0-1 km cost surface distance were significantly more likely to miss a visit, potentially due to stigma of attending clinic within one's community. These results suggest that CBA may mediate the impact of long distances on outcomes.

Awareness and perceived fairness of Option B+ in Malawi: A population-level perspective

Introduction: Policies for rationing antiretroviral therapy (ART) have been subject to on-going ethical debates. Introduced in Malawi in 2011, Option B+ prioritized HIV-positive pregnant women for lifelong ART regardless of the underlying state of their immune system, shifting the logic of allocation away from medical eligibility. Despite the rapid expansion of this policy, we know little about how it has been understood and interpreted by the people it affects.

Methods: We assessed awareness and perceived fairness of the prioritization system for ART among a population-based sample of young women (n = 1440) and their partners (n = 574) in southern Malawi. We use a card-sort technique to elicit understandings of who gets ART under Option B+ and who should be prioritized, and we compare perceptions to actual ART policy using sequence analysis and optimal matching. We then use ordered logistic regression to identify the factors associated with policy awareness.

Results: In 2015, only 30.7% of women and 21.1% of male partners understood how ART was being distributed. There was widespread confusion around whether otherwise healthy HIV-positive pregnant women could access ART under Option B + . Nonetheless, more young adults thought that the fairest policy should prioritize such women than believed the actual policy did. Women who were older, more educated or had recently engaged with the health system through antenatal care or ART had more accurate understandings of Option B + . Among men, policy awareness was lower, and was patterned only by education.

Conclusions: Although most respondents were unaware that Option B+ afforded ART access to healthy-pregnant women, Malawians support the prioritization of pregnant women. Countries adopting Option B+ or other new ART policies such as universal test-and-treat should communicate the policies and their rationales to the public – such transparency would be more consistent with a fair and ethical process and could additionally serve to clarify confusion and enhance retention.​​

Shifting tasks from pharmacy to non-pharmacy personnel for providing antiretroviral therapy to people living with HIV: a systematic review and meta-analysis

OBJECTIVES

Lay people or non-pharmacy health workers with training could dispense antiretroviral therapy (ART) in resource-constrained countries, freeing up time for pharmacists to focus on more technical tasks. We assessed the effectiveness of such task-shifting in low-income and middle-income countries.

METHOD

We conducted comprehensive searches of peer-reviewed and grey literature. Two authors independently screened search outputs, selected controlled trials, extracted data and resolved discrepancies by consensus. We performed random-effects meta-analysis and assessed certainty of evidence using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach.

RESULTS

Three studies with 1993 participants met the inclusion criteria, including two cluster trials conducted in Kenya and Uganda and an individually randomised trial conducted in Brazil. We found very low certainty evidence regarding mortality due to the low number of events. Therefore, we are uncertain whether there is a true increase in mortality as the effect size suggests, or a reduction in mortality between pharmacy and non-pharmacy models of dispensing ART (risk ratio (RR) 1.86, 95% CI 0.44 to 7.95, n=1993, three trials, very low certainty evidence). There may be no differences between pharmacy and non-pharmacy models of dispensing ART on virological failure (risk ratio (RR) 0.92, 95% CI 0.73 to 1.15, n=1993, three trials, low certainty evidence) and loss to follow-up (RR 1.13, 95% CI 0.68 to 1.91, n=1993. three trials, low certainty evidence). We found some evidence that costs may be reduced for the patient and health system when task-shifting is undertaken.

CONCLUSIONS

The low certainty regarding the evidence implies a high likelihood that further research may find the effects of the intervention to be substantially different from our findings. If resource-constrained countries decide to shift ART dispensing and distribution from pharmacy to non-pharmacy personnel, this should be accompanied by robust monitoring and impact evaluation.

Adherence clubs for long-term provision of antiretroviral therapy: cost-effectiveness and access analysis from Khayelitsha, South Africa

OBJECTIVES

As the scale of the South African HIV epidemic calls for innovative models of care that improve accessibility for patients while overcoming chronic human resource shortages, we (i) assess the cost-effectiveness of lay health worker-led group adherence clubs, in comparison with a nurse-driven 'standard of care' and (ii) describe and evaluate the associated patient cost and accessibility differences.

METHODS

Our cost-effectiveness analysis compares an 'adherence club' innovation to conventional nurse-driven care within a busy primary healthcare setting in Khayelitsha, South Africa. In each alternative, we calculate provider costs and estimate rates of retention in care and viral suppression as key measures of programme effectiveness. All results are presented on an annual or per patient-year basis. In the same setting, a smaller sample of patients was interviewed to understand the direct and indirect non-healthcare cost and access implications of the alternatives. Access was measured using McIntyre and colleagues' 2009 framework.

RESULTS

Adherence clubs were the more cost-effective model of care, with a cost per patient-year of $300 vs. $374 and retention in care at 1 year of 98.03% (95% CI 97.67-98.33) for clubs vs. 95.49% (95% CI 95.01-95.94) for standard of care. Viral suppression in clubs was 99.06% (95% CI 98.82-99.27) for clubs vs. 97.20% (95% CI 96.81-97.56) for standard of care. When interviewed, club patients reported fewer missed visits, shorter waiting times and higher acceptability of services compared to standard of care.

CONCLUSIONS

Adherence clubs offer the potential to enhance healthcare efficiency and patient accessibility. Their scale-up should be supported.

Traditional, complementary and alternative medicine use by HIV patients a decade after public sector antiretroviral therapy roll out in South Africa: a cross sectional study

Background

The roll out of antiretroviral therapy in the South African public health sector in 2004 was preceded by the politicisation of HIV-infection which was used to promote traditional medicine for the management of HIV/AIDS. One decade has passed since; however, questions remain on the extent of the use of traditional, complementary and alternative medicine (TCAM) by HIV-infected patients. This study therefore aimed at investigating the prevalence of the use of African traditional medicine (ATM), complementary and alternative medicines (CAM) by adult patients in the eThekwini and UThukela Health Districts, South Africa.

Methods

A cross- sectional study was carried out at 8 public health sector antiretroviral clinics using interviewer-administered semi-structured questionnaires. These were completed from April to October 2014 by adult patients who had been on antiretroviral therapy (ART) for at least three months. Use of TCAM by patients was analysed by descriptive statistics using frequency and percentages with standard error. Where the associated relative error was equal or greater to 0.50, the percentage was rejected as unstable. A p-value <0.05 was estimated as statistically significant.

Results

The majority of the 1748 participants were Black Africans (1685/1748, 96.40 %, SE: 0.00045), followed by Coloured (39/1748, 2.23 %, SE: 0.02364), Indian (17/1748, 0.97 %, SE: 0.02377), and Whites (4/1748, 0.23 %, SE: 0.02324), p < 0.05. The prevalence of ATM use varied prior to (382/1748, 21.85 %) and after ART initiation (142/1748, 8.12 %), p <0.05, specifically by Black African females both before (14.41 %) and after uptake (5.49 %), p < 0.05. Overall, 35 Black Africans, one Coloured and one Indian (37/1748, 2.12 %) reported visiting CAM practitioners for their HIV condition and related symptoms post ART.

Conclusion

Despite a progressive implementation of a successful antiretroviral programme over the first decade of free antiretroviral therapy in the South African public health sector, the use of TCAM is still prevalent amongst a small percentage of HIV infected patients attending public healthcare sector antiretroviral clinics. Further research is needed to explore reasons for use and health benefits or risks experienced by the minority that uses both conventional antiretroviral therapy with TCAM.

The effects of shifting tasks from pharmacy to non-pharmacy personnel for providing antiretroviral therapy to people living with HIV: a systematic review protocol

INTRODUCTION

Shifting selected antiretroviral therapy (ART) tasks from specialised healthcare workers to those with shorter or less formal training has been implemented in resource-limited settings to alleviate critical shortages of human resources for health. However, the specifics of shifting ART dispensing from pharmacy to non-pharmacy personnel have not been addressed in a systematic review, although this can potentially increase access to ART. We will assess the effects of shifting dispensing and distribution of ART and adherence assessment from pharmacy to non-pharmacy personnel in low and middle-income countries.

METHODS AND ANALYSIS

We will search PubMed, CENTRAL, EMBASE, WHO Global Health Library and relevant grey literature for eligible controlled trials. Two authors will screen the search output, select eligible studies, assess risk of bias and extract data from included studies, resolving discrepancies by discussion and consensus. We will perform meta-analysis using both fixed and random effects models, investigate clinical and statistical heterogeneity, and assess our confidence in the overall evidence using standard Cochrane methods, including GRADE.

ETHICS AND DISSEMINATION

Only secondary data will be included in this review and ethics approval is not required. We will disseminate the review findings in various scientific fora, including peer-reviewed journals. The findings may help to inform policy makers in defining the scope of work of healthcare workers, and global recommendations for shifting the dispensing and distribution of ART from pharmacy to non-pharmacy personnel.

TRIAL REGISTRATION NUMBER

CRD42015017034.

Implementation of community-based adherence clubs for stable antiretroviral therapy patients in Cape Town, South Africa

Introduction

Community-based models of antiretroviral therapy (ART) delivery have been recommended to support ART expansion and retention in resource-limited settings. However, the evidence base for community-based models of care is limited. We describe the implementation of community-based adherence clubs (CACs) at a large, public-sector facility in peri-urban Cape Town, South Africa.

Methods

Starting in May 2012, stable ART patients were down-referred from the primary care community health centre (CHC) to CACs. Eligibility was based on self-reported adherence, >12 months on ART and viral suppression. CACs were facilitated by four community health workers and met every eight weeks for group counselling, a brief symptom screen and distribution of pre-packed ART. The CACs met in community venues for all visits including annual blood collection and clinical consultations. CAC patients could send a patient-nominated treatment supporter (“buddy”) to collect their ART at alternate CAC visits. Patient outcomes [mortality, loss to follow-up and viral rebound (>1000 copies/ml)] during the first 18 months of the programme are described using Kaplan–Meier methods.

Results and Discussion

From June 2012 to December 2013, 74 CACs were established, each with 25–30 patients, providing ART to 2133 patients. CAC patients were predominantly female (71%) and lived within 3 km of the facility (70%). During the analysis period, 9 patients in a CAC died (<0.1%), 53 were up-referred for clinical complications (0.3%) and 573 CAC patients sent a buddy to at least one CAC visit (27%). After 12 months in a CAC, 6% of patients were lost to follow-up and fewer than 2% of patients retained experienced viral rebound.

Conclusions

Over a period of 18 months, a community-based model of care was rapidly implemented decentralizing more than 2000 patients in a high-prevalence, resource-limited setting. The fundamental challenge for this out of facility model was ensuring that patients receiving ART within a CAC were viewed as an extension of the facility and part of the responsibility of CHC staff. Further research is needed to support down-referral sooner after ART initiation and to describe patient experiences of community-based ART delivery.

Ten priorities for expanding access to HCV treatment for people who inject drugs in low- and middle-income countries

Of the estimated 130-150 million people who are chronically infected with hepatitis C virus, around 90% reside in low- and middle-income countries. People who inject drugs are disproportionately affected by HCV, with a global estimated prevalence (based on serological reports of HCV antibodies) of 67%; world-wide over 10 million people who inject drugs are infected with HCV. Treatment for HCV has improved dramatically in recent years with the arrival of new direct acting antivirals (DAAs) and this is stimulating considerable efforts to scale up access to treatment. However, treatment coverage among the general population is less than 10% in most countries, and coverage for people who inject drugs is generally much lower. It is estimated that globally around 2 million people who inject drugs need treatment for HCV. The DAAs offer significant potential to rapidly expand access to treatment for HCV. While the ideal combination therapy remains to be established, key characteristics include high efficacy, tolerability, pan-genotypic activity, short treatment duration, oral therapy, affordability, limited drug-drug interactions, and availability as fixed-dose combinations and once daily treatments. This paper outlines 10 key priorities for improving access to HCV treatment for people who inject drugs: (1) affordable access to direct acting antivirals; (2) increased awareness and testing; (3) standardization of treatment; (4) simplification of service delivery; (5) integration of services; (6) peer support; (7) treatment within a framework of comprehensive prevention; (8) tracking progress; (9) dedicated funding; and (10) enabling policies.

Observational research on NCDs in HIV-positive populations: conceptual and methodological considerations

Noncommunicable diseases (NCDs) account for a growing burden of morbidity and mortality among people living with HIV in low- and middle-income countries (LMICs). HIV infection and antiretroviral therapy interact with NCD risk factors in complex ways, and research into this "web of causation" has so far been largely based on data from high-income countries. However, improving the understanding, treatment, and prevention of NCDs in LMICs requires region-specific evidence. Priority research areas include: (1) defining the burden of NCDs among people living with HIV, (2) understanding the impact of modifiable risk factors, (3) evaluating effective and efficient care strategies at individual and health systems levels, and (4) evaluating cost-effective prevention strategies. Meeting these needs will require observational data, both to inform the design of randomized trials and to replace trials that would be unethical or infeasible. Focusing on Sub-Saharan Africa, we discuss data resources currently available to inform this effort and consider key limitations and methodological challenges. Existing data resources often lack population-based samples; HIV-negative, HIV-positive, and antiretroviral therapy-naive comparison groups; and measurements of key NCD risk factors and outcomes. Other challenges include loss to follow-up, competing risk of death, incomplete outcome ascertainment and measurement of factors affecting clinical decision making, and the need to control for (time-dependent) confounding. We review these challenges and discuss strategies for overcoming them through augmented data collection and appropriate analysis. We conclude with recommendations to improve the quality of data and analyses available to inform the response to HIV and NCD comorbidity in LMICs.

Practicalities and challenges in re-orienting the health system in Zambia for treating chronic conditions

Background

The rapid evolution in disease burdens in low- and middle income countries is forcing policy makers to re-orient their health system towards a system which has the capability to simultaneously address infectious and non-communicable diseases. This paper draws on two different but overlapping studies which examined how actors in the Zambian health system are re-directing their policies, strategies and service structures to include the provision of health care for people with chronic conditions.

Methods

Study methods in both studies included semi-structured interviews with government health officials at national level, and governmental and non-governmental health practitioners operating from community-, primary health care to hospital facility level. Focus group discussions were conducted with staff, stakeholders and caregivers of programmes providing care and support at community- and household levels. Study settings included urban and rural sites.

Results

A series of adaptations transformed the HIV programme from an emergency response into the first large chronic care programme in the country. There are clear indications that the Zambian government is intending to expand this reach to patients with non-communicable diseases. Challenges to do this effectively include a lack of proper NCD prevalence data for planning, a concentration of technology and skills to detect and treat NCDs at secondary and tertiary levels in the health system and limited interest by donor agencies to support this transition.

Conclusion

The reorientation of Zambia’s health system is in full swing and uses the foundation of a decentralised health system and presence of local models for HIV chronic care which actively involve community partners, patients and their families. There are early warning signs which could cause this transition to stall, one of which is the financial capability to resource this process.

Task shifting from doctors to non-doctors for initiation and maintenance of antiretroviral therapy

BACKGROUND

The high levels of healthcare worker shortage is recognised as a severe impediment to increasing patients' access to antiretroviral therapy. This is particularly of concern where the burden of disease is greatest and the access to trained doctors is limited.This review aims to better inform HIV care programmes that are currently underway, and those planned, by assessing if task-shifting care from doctors to non-doctors provides both high quality and safe care for all patients requiring antiretroviral treatment.

OBJECTIVES

To evaluate the quality of initiation and maintenance of HIV/AIDS care in models that task shift care from doctors to non-doctors.

SEARCH METHODS

We conducted a comprehensive search to identify all relevant studies regardless of language or publication status (published, unpublished, in press, and in progress) from 1 January 1996 to 28 March 2014, with major HIV/AIDS conferences searched 23 May 2014. We had also contacted relevant organizations and researchers. Key words included MeSH terms and free-text terms relevant to 'task shifting', 'skill mix', 'integration of tasks', 'service delivery' and 'health services accessibility'.

SELECTION CRITERIA

We included controlled trials (randomised or non-randomised), controlled-before and after studies, and cohort studies (prospective or retrospective) comparing doctor-led antiretroviral therapy delivery to delivery that included another cadre of health worker other than a doctor, for initiating treatment, continuing treatment, or both, in HIV infected patients.

DATA COLLECTION AND ANALYSIS

Two authors independently screened titles, abstracts and descriptor terms of the results of the electronic search and applied our eligibility criteria using a standardized eligibility form to full texts of potentially eligible or uncertain abstracts. Two reviewers independently extracted data on standardized data extraction forms. Where possible, data were pooled using random effects meta-analysis. We assessed evidence quality with GRADE methodology.

MAIN RESULTS

Ten studies met our inclusion criteria, all of which were conducted in Africa. Of these four were randomised controlled trials while the remaining six were cohort studies.From the trial data, when nurses initiated and provided follow-up HIV therapy, there was high quality evidence of no difference in death at one year, unadjusted risk ratio was 0.96 (95% CI 0.82 to 1.12), one trial, cluster adjusted n = 2770. There was moderate quality evidence of lower rates of losses to follow-up at one year, relative risk of 0.73 (95% CI 0.55 to 0.97). From the cohort data, there was low quality evidence that there may be an increased risk of death in the task shifting group, relative risk 1.23 (95% CI 1.14 to 1.33, two cohorts, n = 39 160) and very low quality data reporting no difference in patients lost to follow-up between groups, relative risk 0.30 (95% CI 0.05 to 1.94).From the trial data, when doctors initiated therapy and nurses provided follow-up, there was moderate quality evidence that there is probably no difference in death compared with doctor-led care at one year, relative risk of 0.89 (95% CI 0.59 to 1.32), two trials, cluster adjusted n = 4332. There was moderate quality evidence that there is probably no difference in the numbers of patients lost to follow-up at one year, relative risk 1.27 (95% CI 0.92 to 1.77), P = 0.15. From the cohort data, there is very low quality data that death at one year may be lower in the task shifting group, relative risk 0.19 (95% CI 0.05 to 0.78), one cohort, n = 2772, and very low quality evidence that loss to follow-up was reduced, relative risk 0.34 (95% CI 0.18 to 0.66).From the trial data, for maintenance therapy delivered in the community there was moderate quality evidence that there is probably no difference in mortality when doctors deliver care in the hospital or specially trained field workers provide home-based maintenance care and antiretroviral therapy at one year, relative risk 1.0 (95% CI 0.62 to 1.62), 1 trial, cluster adjusted n = 559. There is moderate quality evidence from this trial that losses to follow-up are probably no different at one year, relative risk 0.52 (0.12 to 2.3), P = 0.39. The cohort studies did not report on one year follow-up for these outcomes.Across the studies that reported on virological and immunological outcomes, there was no clear evidence of difference whether a doctor or nurse or clinical officer delivered therapy. Three studies report on costs to patients, indicating a reduction in travel costs to treatment facilities where task shifting was occurring closer to patients homes. There is conflicting evidence regarding the relative cost to the health system, as implementation of the strategy may increase costs. The two studies reporting the patient and staff perceptions of the quality of care, report good acceptability of the service by patients, and general acceptance by doctors of the shifting of roles. One trial reported on the time to initiation of antiretroviral therapy, finding no clear evidence of a difference between groups. The same trial reports on new diagnosis of tuberculosis which favours nurse initiation of HIV care for increasing the numbers of diagnoses of tuberculosis made.

AUTHORS' CONCLUSIONS

Our review found moderate quality evidence that shifting responsibility from doctors to adequately trained and supported nurses or community health workers for managing HIV patients probably does not decrease the quality of care and, in the case of nurse initiated care, may decrease the numbers of patients lost to follow-up.

The dual impact of antiretroviral therapy and sexual behaviour changes on HIV epidemiologic trends in Uganda: a modelling study

Objectives

Antiretroviral therapy (ART) availability in a population may influence risky sexual behaviour. We examine the potential impact of ART on the HIV epidemic, incorporating evidence for the impact that ART may have on risky sexual behaviour.

Methods

A mathematical model, parameterised using site-specific data from Uganda and worldwide literature review, was used to examine the likely impact of ART on HIV epidemiologic trends. We varied assumptions about rates of initiating ART, and changes in sexual partner turnover rates.

Results

Modelling suggests that ART will reduce HIV incidence over 20 years, and increase prevalence. Even in the optimistic scenario of ART enrollment beginning after just five months of infection (in HIV stage 2), prevalence is estimated to rise from a baseline of 10.5% and 8.3% among women and men, respectively, to at least 12.1% and 10.2%, respectively. It will rise further if sexual disinhibition occurs or infectiousness while on ART is slightly higher (2% female to male, rather than 0.5%). The conditions required for ART to reduce prevalence over this period are likely too extreme to be achievable. For example, if ART enrolment begins in HIV stage 1 (within the first 5 months of infection), and if risky sexual behaviour does not increase, then 3 of our 11 top fitting results estimate a potential drop in HIV prevalence by 2025. If sexual risk taking rises, it will have a large additional impact on expected HIV prevalence. Prevalence will rise despite incidence falling, because ART extends life expectancy.

Conclusions

HIV prevalence will rise. Even small increases in partner turnover rates will lead to an additional substantial increase in HIV prevalence. Policy makers are urged to continue HIV prevention activities, including promoting sex education, and to be prepared for a higher than previously suggested number of HIV infected people in need of treatment.

Towards an integrated framework for accelerating the end for the global HIV epidemic among young people

For decades the HIV epidemic has exacted an enormous toll worldwide. However, trend analyses have discerned significant declines in the overall prevalence of HIV over the last two decades. More recently, advances in biomedical, behavioural, and structural interventions offer considerable promise in the battle against generalised epidemics. Despite advances in the prevention of transmission and new infections, morbidity and mortality of HIV among young people remains a considerable concern for individuals, couples, families, communities, practitioners, and policy makers around the globe. To accelerate the end of the global HIV epidemic among young people, we must merge existing efficacious interventions with more novel, cost-effective implementation strategies to develop integrated, multilevel combination interventions. The benefits of conceptualising the HIV epidemic more broadly and adopting ecological frameworks for the development of HIV prevention programmes are critical.

Antiretroviral therapy for prevention is a combination strategy

In the past several years, the debate of "treatment vs prevention" has shifted with the introduction of the concept of "treatment as prevention," (TasP), stemming from a series of compelling observational, ecological, and modeling studies as well as HPTN 052, a randomized clinical trial, demonstrating that use of ART is associated with a decrease in HIV transmission. In addition to TasP being viewed as 1 intervention in a combination strategy for HIV Prevention, TasP is, in and of itself, a combination of multiple interventions that need to be implemented with high coverage in order to achieve its potential impact.

Non-physician clinician provided HIV treatment results in equivalent outcomes as physician-provided care: a meta-analysis

INTRODUCTION

A severe healthcare worker shortage in sub-Saharan Africa is inhibiting the expansion of HIV treatment. Task shifting, the transfer of antiretroviral therapy (ART) management and initiation from doctors to nurses and other non-physician clinicians, has been proposed to address this problem. However, many health officials remain wary about implementing task shifting policies due to concerns that non-physicians will provide care inferior to physicians. To determine if non-physician-provided HIV care does result in equivalent outcomes to physician-provided care, a meta-analysis was performed.

METHODS

Online databases were searched using a predefined strategy. The results for four primary outcomes were combined using a random effects model with sub-groups of non-physician-managed ART and -initiated ART. TB diagnosis rates, adherence, weight gain and patient satisfaction were summarized qualitatively.

RESULTS

Mortality (N=59,666) had similar outcomes for non-physicians and physicians, with a hazard ratio of 1.05 (CI: 0.88-1.26). The increase in CD4 levels at one year, as a difference in means of 2.3 (N=17,142, CI: -12.7-17.3), and viral failure at one year, as a risk ratio of 0.89 (N=10,344, CI: 0.65-1.23), were similar for physicians and non-physicians. Interestingly, loss to follow-up (LTFU) (N=53,435) was reduced for non-physicians with a hazard ratio of 0.72 (CI: 0.56-0.94). TB diagnosis rates, adherence and weight gain were similar for non-physicians and physicians. Patient satisfaction appeared higher for non-physicians in qualitative components of studies and was attributed to non-physicians spending more time with patients as well as providing more holistic care.

CONCLUSIONS

Non-physician-provided HIV care results in equivalent outcomes to care provided by physicians and may result in decreased LTFU rates.

Decentralising HIV treatment in lower- and middle-income countries

BACKGROUND

Policy makers, health staff and communities recognise that health services in lower- and middle-income countries need to improve people's access to HIV treatment and retention to treatment programmes. One strategy is to move antiretroviral delivery from hospitals to more peripheral health facilities or even beyond health facilities. This could increase the number of people with access to care, improve health outcomes, and enhance retention in treatment programmes. On the other hand, providing care at less sophisticated levels in the health service or at community-level may decrease quality of care and result in worse health outcomes. To address these uncertainties, we summarised the research studies examining the risks and benefits of decentralising antiretroviral therapy service delivery.

OBJECTIVES

To assess the effects of various models that decentralised HIV treatment and care to more basic levels in the health system for initiating and maintaining antiretroviral therapy.

SEARCH METHODS

We conducted a comprehensive search to identify all relevant studies regardless of language or publication status (published, unpublished, in press, and in progress) from 1 January 1996 to 31 March 2013, and contacted relevant organisations and researchers. The search terms included 'decentralisation', 'down referral', 'delivery of health care', and 'health services accessibility'.

SELECTION CRITERIA

Our inclusion criteria were controlled trials (randomised and non-randomised), controlled-before and after studies, and cohorts (prospective and retrospective) in which HIV-infected people were either initiated on antiretroviral therapy or maintained on therapy in a decentralised setting in lower- and middle-income countries. We define decentralisation as providing treatment at a more basic level in the health system to the comparator.

DATA COLLECTION AND ANALYSIS

Two authors applied the inclusion criteria and extracted data independently. We designed a framework to describe different decentralisation strategies, and then grouped studies against these strategies. Data were pooled using random-effects meta-analysis. Because loss to follow up in HIV programmes is known to include some deaths, we used attrition as our primary outcome, defined as death plus loss to follow-up. We assessed evidence quality with GRADE methodology.

MAIN RESULTS

Sixteen studies met the inclusion criteria, all but one were from Africa, comprising two cluster randomised trials and 14 cohort studies. Antiretroviral therapy started at a hospital and maintained at a health centre (partial decentralisation) probably reduces attrition (RR 0.46, 95% CI 0.29 to 0.71, 4 studies, 39 090 patients, moderate quality evidence). There may be fewer patients lost to care with this model (RR 0.55, 95% CI 0.45 to 0.69, low quality evidence).We are uncertain whether there is a difference in attrition for antiretroviral therapy started and maintained at a health centre (full decentralisation) compared to a hospital at 12 months (RR 0.70, 95% CI 0.47 to 1.02; four studies, 56 360 patients, very low quality evidence), but there are probably fewer patients lost to care with this model (RR 0.3, 95% CI 0.17 to 0.54, moderate quality evidence).When antiretroviral maintenance therapy is delivered at home by trained volunteers, there is probably no difference in attrition at 12 months (RR 0.95, 95% CI 0.62 to 1.46, two trials, 1453 patients, moderate quality evidence).

AUTHORS' CONCLUSIONS

Decentralisation of HIV care aims to improve patient access and retention in care. Most data were from good quality cohort studies but confounding between site of treatment and outcomes cannot be excluded. Nevertheless, this review found that attrition appears to be lower in partial decentralisation models of treatment, where antiretrovirals were started at hospital and continued in the health centre; with antiretroviral drugs started and continued at health centres, no difference in attrition was detected, but there were fewer patients lost to care. For antiretroviral therapy provided at home by trained volunteers, no difference in outcomes were detected when compared to facility-based care.

The impact of social context on self-management in women living with HIV

HIV self-management is central to the health of people living with HIV and is comprised of the daily tasks individuals employ to manage their illness. Women living with HIV are confronted with social context vulnerabilities that impede their ability to conduct HIV self-management behaviors, including demanding social roles, poverty, homelessness, decreased social capital, and limited access to health care. We examined the relationship between these vulnerabilities and HIV self-management in a cross-sectional secondary analysis of 260 women living with HIV from two U.S. sites. All social context variables were assessed using validated self-report scales. HIV Self-Management was assessed using the HIV Self-Management Scale that measures daily health practices, HIV social support, and the chronic nature of HIV. Data were analyzed using appropriate descriptive statistics and multivariable regression. Mean age was 46 years and 65% of participants were African-American. Results indicated that social context variables, particularly social capital, significantly predicted all domains of HIV self-management including daily health practices (F = 5.40, adjusted R(2) = 0.27, p < 0.01), HIV social support (F = 4.50, adjusted R(2) = 0.22, p < 0.01), and accepting the chronic nature of HIV (F = 5.57, adjusted R(2) = 0.27, p < 0.01). We found evidence to support the influence of the traditional social roles of mother and employee on the daily health practices and the chronic nature of HIV domains of HIV self-management. Our data support the idea that women's social context influences their HIV self-management behavior. While social context has been previously identified as important, our data provide new evidence on which aspects of social context might be important targets of self-management interventions for women living with HIV. Working to improve social capital and to incorporate social roles into the daily health practices of women living with HIV may improve the health of this population.

Increased mortality among HIV-positive men on antiretroviral therapy: survival differences between sexes explained by late initiation in Uganda

Background

We aimed to assess the relationship between gender and survival among adult patients newly enrolled on antiretroviral therapy (ART) in Uganda. We also specifically examined the role of antenatal services in favoring women’s access to HIV care.

Methods

From an observational cohort study, we assessed survival and used logistic regression and differences in means to compare men and women who did not access care through antenatal services. Differences were assessed on measures of disease progression (WHO stage and CD4 count) and demographic (age, marital status, and education), behavioral (sexual activity, disclosure to partner, and testing), and clinical variables (hepatitis B and C, syphilis, malaria, and anemia). A mediational analysis that considered gender as the initial variable, time to death as the outcome, initial CD4 count as the mediator, and age as a covariate was performed using an accelerated failure time model with a Weibull distribution.

Results

Between 2004 and 2011, a total of 4775 patients initiated ART, and after exclusions 4537 (93.2%) were included in analysis. Men initiating ART were more likely to have a WHO disease stage III or IV (odds ratio: 1.46, 95% confidence interval [CI]: 1.29–1.66), and lower CD4 cell counts compared to women (median baseline CD4 124 cells/mm³, interquartile range [IQR]: 43–205 versus 147 cells/mm³, IQR: 68–212, P-value < 0.0001). Men were at an increased risk of death compared to women (hazard ratio: 1.38, 95% CI: 1.03–1.83). Baseline CD4 cell counts accounted for 43% of the increased risk of death in men (95% CI: 22%–113%). Access to care via antenatal services did not explain differences in outcomes.

Conclusion

In this cohort there is a marked increase in risk of mortality for men and approximately half of it can be attributed to their later engagement in care. More effort is required to engage men in care in a timely manner.