Factors associated with access to HIV care services in eastern Uganda: the Kumi home based HIV counseling and testing program experience

Factors associated with HIV-positive status awareness among adults with long term HIV infection in four countries in the East and Southern Africa region: A multilevel approach

Antiretroviral treatment (ART) appropriately and regularly used decreases the human immunodeficiency virus (HIV) viral load in the bloodstream, preventing HIV-infected people from spreading the infection to others. Disparities in ART adoption persists in East and Southern Africa, with low HIV-positive status knowledge being the primary factor. We investigated individual and household characteristics of HIV-positive status awareness among adults with long-term HIV infection in four East and Southern African countries: Eswatini, Malawi, Tanzania, and Zimbabwe. The study analyzed data from surveys conducted in Eswatini, Malawi, Tanzania, and Zimbabwe in 2015-2016. Only individuals who tested positive for HIV through rapid tests were included in the analysis. Those who already knew they were HIV-positive were categorized as aware, while those who reported being negative, never tested, or didn't know their status were categorized as unaware. Statistical models were used to examine various factors related to HIV awareness. Pooled and country-specific odds ratios were computed. The percentage of people who knew they had HIV ranged from 58% (Tanzania and Malawi) to 87% (Eswatini). After adjusting for other variables, young persons in all countries were less likely to be aware of their HIV-positive status. Gender, marital status, education, working status, household wealth, and urbanization level of households were also associated with HIV-positive status awareness but inconsistent across countries. HIV-positive status awareness in these four East and Southern African nations remained unsatisfactory as compared to the United Nations' 95% guideline, indicating that testing and knowledge of HIV testing in this region still has a lot of potential for improvement. The observed variations among nations may be attributable to differences in HIV pandemic culture and policies. The findings of this study will assist governments determining which subpopulations to target to boost adoption of HIV testing services, as well as in designing and development of policies.

Factors Associated with Linkage to HIV Care Among Oral Self-Tested HIV Positive Adults in Uganda

BACKGROUND

HIV oral self-testing (HIVST) was rolled out in Uganda in 2018. However, data reported by public facilities show that less than 60% of oral self-tested HIV positive adults were linked to HIV care. This study set out to determine the factors associated with linkage to HIV care among adults with positive HIV oral self-test results in Uganda.

METHODS

A cross-sectional study was carried out at Nabweru HCIII and Entebbe Hospital in central Uganda. The study reviewed medical records from January 2019 to May 2020 and successfully invited 144 self-tested HIV positive participants for the quantitative interview process. Data on socio-demographics and health-related characteristics were collected. Bivariate and multivariable analysis was used to determine the factors associated with linkage to care.

RESULTS

The proportion of participants linked to HIV care was 69.6% (100/144). The majority of the participants were female (71%), with a mean age of 29 (±8) years. Participants within age groups of 31-35 years and 41-60 years, who used directly assisted HIVST, disclosed their HIV status to their sexual partners, are ready to start ART, do not consume alcohol and having a supportive sexual partner were more likely to be linked to HIV care. Single participants, separated/divorced, female, fear unfair treatment after HIV status disclosure and those who fear ART side effects were less likely to be linked to HIV care.

CONCLUSION

Our study showed that less than 70% were linked to HIV care. It also shows that HIV status disclosure, readiness to start ART, type of HIVST used, fear of ART side effects, and being divorced/separated negatively associated with linkage to HIV care among self-test HIV positive adults. There is a need for HIV programs to address the above factors to improve linkage to HIV care to realize the national targets towards the UNAIDs 2035 goals.

Loss to follow-up and associated factors among adult people living with HIV at public health facilities in Wakiso district, Uganda: a retrospective cohort study

BACKGROUND

Loss to follow-up (LTFU) from care among people living with HIV (PLHIV) is thought to be more common in the public setting compared to the private health care. It is anticipated that the problem may become worse with the current "test and treat" policy in Uganda due to the likely increases in patient loads and its attendant pressure on health care providers to support patient counseling. This study determined the incidence and factors associated with LTFU from HIV care among adult PLHIV in public health facilities in Wakiso district, Uganda.

METHODS

This was a retrospective cohort study that involved the review of 646 records of patients initiated on antiretroviral therapy (ART) between January 1st, 2015 and December 31st, 2017 at 13 randomly selected public health facilities in Wakiso district. The cox proportional hazards regression was used to determine the factors associated with LTFU. The results were supported by sequential in-depth and key informant interviews to explore reasons for LTFU.

RESULTS

Of the 646 patients enrolled, 391 were female (60.5%), 282 were below 30 years (43.6%) and 207 were married (50.1%). A total of 216 patients (33.4%) had no documented outcomes and were considered LTFU. The incidence of LTFU was 21 per 1000 person months (95% confidence interval (CI): 18-25 per 1000 person months). Factors associated with LTFU included having normal weight compared to underweight (adjusted hazard ratio (aHR) 0.64, 95% CI: 0.45-0.90, p = 0.011), receiving HIV care from hospitals compared to lower level facilities (aHR 0.22, 95% CI: 0.12-0.41, p < 0.001), and no telephone contact compared to those with a telephone contact (aHR 2.16, 95% CI: 1.33-3.51, p = 0.002). Stigmatization and long waiting times were the prominent reasons for LTFU reported from the in-depth and key informant interviews.

CONCLUSIONS

The incidence of LTFU in public health facilities in Uganda is quite high and is associated with being underweight, not having a telephone contact to receive reminders and receiving care at lower level facilities. Early diagnosis, routine use of patient address locator forms and improved quality of HIV care at lower level health facilities may reduce LTFU among PLHIV.

Perceptions among transgender women of factors associated with the access to HIV/AIDS-related health services in Yogyakarta, Indonesia

Access to HIV/AIDS-related health services among transgender women living with HIV is still a major public health issue in many developing countries, and Indonesia is not an exception. However, reportedly compared to other settings in the country, transgender women in Yogyakarta have a good access to the HIV-related health services. This study aimed to explore perceptions among transgender women living with HIV, locally known as waria, of factors supportive of their access to the services in Yogyakarta, Indonesia. A qualitative inquiry using in-depth interview method was conducted from December 2017 to February 2018 to collect the data from a selection of waria living with HIV (n = 29) recruited using both purposive and snowball sampling techniques. Data analysis employed a thematic approach which was guided by the framework analysis for qualitative data. The findings indicated several health service system-related determinants supportive of waria’s access to HIV/AIDS-related health services. These included the availability of the services, the simplicity and convenience of accessibility to the services and the comfort felt by the participants while accessing the services. Health professionals’ positive attitudes during healthcare provision, social relationships between waria and health professionals, proximity to healthcare facilities, free access to the services, and information sessions on HIV infection and prevention were also reported to enable participants’ access to the services. These findings call to efforts and strengthening of HIV health service system to support and provide equal access to HIV/AIDS-related services including to all Indonesians living with HIV, but more so for transgender women and other high-risk groups such as sex workers and their clients and men who have sex with men.

Facilitators to Accessibility of HIV/AIDS-Related Health Services among Transgender Women Living with HIV in Yogyakarta, Indonesia

The study aimed to explore facilitators or enabling factors that enhance accessibility (defined as the opportunity to be able to use) to HIV/AIDS-related health services among HIV positive transgender women, also known as Waria in Yogyakarta, Indonesia. A qualitative study employing one-on-one in-depth interviews was conducted from December 2017 to February 2018. Participants were HIV positive Waria recruited using purposive and snowball sampling techniques. Data were analysed using the framework analysis for qualitative research. The findings showed that participants' knowledge of HIV/AIDS and the availability of HIV/AIDS-related health services were enablers to the services accessibility. Emotional support from fellow Waria displayed in various ways, such as kind and caring attention, attentive listening, and encouraging words, was an important social support that played a role in supporting Waria's accessibility to the services. HIV/AIDS-related health service information shared personally or jointly by fellow Waria and instrumental support including helping each other to collect antiretroviral (ARV) from hospitals or community health centres, contacting ambulance in emergency situations, accompanying each other to health service facilities, and helping those without the health insurance to receive free health services were also the social support enabling accessibility to the services among the study participants. Appraisal support such as providing constructive feedback and affirmation was another enabling factor to Waria's accessibility to the services. The findings indicate the needs to broadly disseminate information and educate Waria populations and their significant others about HIV/AIDS and related health services to raise their awareness of HIV/AIDS and acceptance of HIV/AIDS positive individuals. Educating and broadly disseminating this information in other settings in the country will also increase accessibility to the HIV/AIDS services among Waria, their families, and communities addressing the currently existing inequities in health. The findings also reinforce the importance of the establishment of Waria peer-support groups within Waria communities and the involvement of Waria in HIV/AIDS activities and programs, which may increase their awareness of HIV/AIDS, and accessibility to HIV/AIDS-related health services.

Enrollment in HIV Care and Treatment Clinic and Associated Factors Among HIV Diagnosed Patients in Magu District, Tanzania

HIV care and treatment clinics (CTC) are important for management of HIV morbidity and mortality, and to reduce HIV transmission. Enrollment in HIV care and treatment clinics remains low in many developing countries. We followed up 632 newly diagnosed HIV patients aged 15 years and above from Magu District, Tanzania. Logistic regression was used to assess factors significantly associated with enrollment for CTC services. Kaplan-Meier plots and log-rank tests were used to evaluate differences in timing uptake of services. Among 632 participants, 214 (33.9%) were enrolled in CTC, and of those enrolled 120 (56.6%) took longer than 3 months to enroll. Those living in more rural villages were less likely to be enrolled than in the villages with semi-urban settings (OR 0.36; 95% CI 0.17-0.76). Moreover, those with age group 35-44 years and with age group 45 years and above were 2 times higher odds compared to those with age group 15-24 years, (OR 2.03; 95% CI 1.05-3.91) and (OR 2.69; 95% CI 1.40-5.18) respectively. Enrollment in the CTC in Tanzania is low. To increase uptake of antiretroviral therapy, it is critical to improve linkage between HIV testing and care services, and to rollout these services into the primary health facilities.

Brief Report: "Give Me Some Time": Facilitators of and Barriers to Uptake of Home-Based HIV Testing During Household Contact Investigation for Tuberculosis in Kampala, Uganda

BACKGROUND

Integrating home-based HIV counseling and testing (HCT) with tuberculosis (TB) evaluation could improve the uptake of HIV testing among household contacts of patients with active TB. We sought to identify the facilitators of and barriers to HCT during household contact investigation for TB in Kampala, Uganda.

METHODS

We nested semi-structured interviews with 28 household contacts who were offered home-based HCT in a household-randomized trial of home-based strategies for TB contact investigation. Respondents reflected on their experiences of the home visit, the social context of the household, and their decision to accept or decline HIV testing. We used content analysis to identify and evaluate facilitators of and barriers to testing, then categorized the emergent themes using the Capability, Opportunity, Motivation, and Behavior (COM-B) model.

RESULTS

Facilitators included a preexisting desire to confirm HIV status or to show support for the index TB patient; a perception that home-based services are convenient; and positive perceptions of lay health workers. Key barriers included fear of results and feeling psychologically unprepared to receive results. The social influence of other household members operated as both a facilitator and a barrier.

CONCLUSIONS

Preexisting motivation, psychological readiness to test, and the social context of the household are major contributors to the decision to test for HIV at home. Uptake might be improved by providing normalizing information about HCT before the visit, by offering a second HCT opportunity, by offering self-tests with follow-up counseling, or by introducing HCT using "opt-out" language.

Barriers to HIV testing among male clients of female sex workers in Indonesia

BACKGROUND

Frequent engagement of men in sexual encounters with female sex workers (FSWs) without using condoms places them at a high risk for HIV infection. HIV testing has been noted to be among important strategies to prevent HIV transmission and acquisition. However, it is known that not all men willingly undertake an HIV test as a way to prevent HIV transmission and/or acquisition. This study aimed to identify barriers to accessing HIV testing services among men who are clients of FSWs (clients) in Belu and Malaka districts, Indonesia.

METHODS

A qualitative inquiry employing face to face open ended interviews was conducted from January to April 2017. The participants (n = 42) were clients of FSWs recruited using purposive and snowball sampling techniques. Data were analysed using a qualitative data analysis framework.

RESULTS

Findings indicated three main barriers of accessing HIV testing services by clients. These included: (1) personal barriers (lack of knowledge of HIV/AIDS and HIV testing availability, and unwillingness to undergo HIV testing due to low self-perceived risk of HIV and fear of the test result); (2) health care service provision barriers (lack of trust in health professionals and limited availability of medication including antiretroviral (ARV)); and (3) social barriers (stigma and discrimination, and the lack of social supports).

CONCLUSIONS

These findings indicated multilevelled barriers to accessing HIV testing services among participants, who are known to be among key population groups in HIV care. Actions to improve HIV/AIDS-related health services accessibility are required. The dissemination of the knowledge and information on HIV/AIDS and improved available of HIV/AIDS-related services are necessary actions to improve the personal levelled barriers. System wide barriers will need improved practices and health policies to provide patients friendly and accessible services. The societal levelled barriers will need a more broad societal approach including raising awareness in the community and enhanced discussions about HIV/AIDS issues in order to normalise HIV in the society.

A Framework for Health Communication Across the HIV Treatment Continuum

Supplemental Digital Content is Available in the Text.

Background:

As test and treat rolls out, effective interventions are needed to address the determinants of outcomes across the HIV treatment continuum and ensure that people infected with HIV are promptly tested, initiate treatment early, adhere to treatment, and are virally suppressed. Communication approaches offer viable options for promoting relevant behaviors across the continuum.

Conceptual Framework:

This article introduces a conceptual framework, which can guide the development of effective health communication interventions and activities that aim to impact behaviors across the HIV treatment continuum in low- and medium-income countries. The framework includes HIV testing and counseling, linkage to care, retention in pre-antiretroviral therapy and antiretroviral therapy initiation in one single-stage linkage to care and treatment, and adherence for viral suppression. The determinants of behaviors vary across the continuum and include both facilitators and barriers with communication interventions designed to focus on specific determinants presented in the model. At each stage, relevant determinants occur at the various levels of the social–ecological model: intrapersonal, interpersonal, health services, community, and policy. Effective health communication interventions have mainly relied on mHealth, interpersonal communication through service providers and peers, community support groups, and treatment supporters.

Discussion:

The conceptual framework and evidence presented highlight areas across the continuum where health communication can significantly impact treatment outcomes to reach the 90-90-90 goals by strategically addressing key behavioral determinants. As test and treat rolls out, multifaceted health communication approaches will be critical.

Linkage to HIV care after home-based HIV counselling and testing in sub-Saharan Africa: a systematic review

BACKGROUND

Home-based HIV counselling and testing (HBHCT) has the potential to increase HIV testing uptake in sub-Saharan Africa (SSA), but data on linkage to HIV care after HBHCT are scarce. We conducted a systematic review of linkage to care after HBHCT in SSA.

METHODS

Five databases were searched for studies published between 1st January 2000 and 19th August 2016 that reported on linkage to care among adults newly identified with HIV infection through HBHCT. Eligible studies were reviewed, assessed for risk of bias and findings summarised using the PRISMA guidelines.

RESULTS

A total of 14 studies from six countries met the eligibility criteria; nine used specific strategies (point-of-care CD4 count testing, follow-up counselling, provision of transport funds to clinic and counsellor facilitation of HIV clinic visit) in addition to routine referral to facilitate linkage to care. Time intervals for ascertaining linkage ranged from 1 week to 12 months post-HBHCT. Linkage ranged from 8.2% [95% confidence interval (CI), 6.8-9.8%] to 99.1% (95% CI, 96.9-99.9%). Linkage was generally lower (<33%) if HBHCT was followed by referral only, and higher (>80%) if additional strategies were used. Only one study assessed linkage by means of a randomised trial. Five studies had data on cotrimoxazole (CTX) prophylaxis and 12 on ART eligibility and initiation. CTX uptake among those eligible ranged from 0% to 100%. The proportion of persons eligible for ART ranged from 16.5% (95% CI, 12.1-21.8) to 77.8% (95% CI, 40.0-97.2). ART initiation among those eligible ranged from 14.3% (95% CI, 0.36-57.9%) to 94.9% (95% CI, 91.3-97.4%). Additional linkage strategies, whilst seeming to increase linkage, were not associated with higher uptake of CTX and/or ART. Most of the studies were susceptible to risk of outcome ascertainment bias. A pooled analysis was not performed because of heterogeneity across studies with regard to design, setting and the key variable definitions.

CONCLUSION

Only few studies from SSA investigated linkage to care among adults newly diagnosed with HIV through HBHCT. Linkage was often low after routine referral but higher if additional interventions were used to facilitate it. The effectiveness of linkage strategies should be confirmed through randomised controlled trials.

Challenges in initiating antiretroviral therapy for all HIV-infected people regardless of CD4 cell count

Introduction

Recently published large randomized controlled trials, START, TEMPRANO and HPTN 052 show the clinical benefit of early initiation of antiretroviral treatment (ART) in HIV-infected persons and in reducing HIV transmission. The trials influenced the World Health Organization (WHO) decision to issue updated recommendations to prescribe ART to all individuals living with HIV, irrespective of age and CD4 cell count.

Discussion

It is clear that the new 2015 WHO recommendations if followed, will change the face of the HIV epidemic and probably curb its burden over time. Implementation however, requires that health systems, especially those in low and middle-income settings, be ready to face this challenge on a large scale. HIV prevention and treatment are easy in theory yet hard in practice. The new WHO guidelines for initiation of ART regardless of CD4 cell count will lead to upfront increases in the costs of healthcare delivery as the goal is to treat all those now newly eligible for ART. Around 22 million people living with HIV qualify and will therefore require ART. Related challenges immediately follow: firstly, that everyone must be tested for HIV; secondly, that anyone who has had an HIV test should know their result and understand its significance; and, thirdly, that every person identified as HIV-positive should receive and remain on ART. The emergence of HIV drug resistant strains when treatment is started at higher CD4 cell count thresholds is a further concern as persons on HIV treatment for longer periods of time are at increased risk of intermittent medication adherence.

Conclusions

The new WHO recommendations for ART are welcome, but lacking as they fail to consider meaningful solutions to the challenges inherent to implementation. They fail to incorporate actual strategies on how to disseminate and adopt these far-reaching guidelines, especially in sub-Saharan Africa, an area with weak healthcare infrastructures. Well-designed, high-quality research is needed to assess the feasibility, safety, acceptability, impact, and cost of innovations such as the universal voluntary testing and immediate treatment approaches, and broad consultation must address community, human rights, ethical, and political concerns.

Electronic supplementary material

The online version of this article (doi:10.1186/s40249-016-0179-9) contains supplementary material, which is available to authorized users.