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Iguna S, Getahun M, Lewis-Kulzer J, Odhiambo G, Adhiambo F, Montoya L, Petersen ML, Bukusi E, Odeny T, Geng E, Camlin CS. Attitudes towards and experiences with economic incentives for engagement in HIV care and treatment: Qualitative insights from a randomized trial in Kenya. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000204. [PMID: 36962322 PMCID: PMC10021832 DOI: 10.1371/journal.pgph.0000204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 01/19/2022] [Indexed: 11/18/2022]
Abstract
Growing literature has shown heterogenous effects of conditional cash incentives (CCIs) on HIV care retention. The field lacks insights into reasons why incentives impact various patients in different ways-differences that may be due to variations in psychological and social mechanisms of effect. A deeper understanding of patients' perceptions and experiences of CCIs for retention may help to clarify these mechanisms. We conducted a qualitative study embedded in the ADAPT-R trial (NCT#02338739), a sequential multiple assignment randomized trial (SMART) that evaluated economic incentives to support retention in HIV care among persons living with HIV (PLHIV) initiating antiretroviral therapy in Kenya. Participants who attended their scheduled clinic visits received an incentive of approximately $4 each visit. Interviews were conducted between July 2016 and June 2017 with 39 participants to explore attitudes and experiences with economic incentives conditional on care engagement. Analyses revealed that incentives helped PLHIV prioritize care-seeking by alleviating transport barriers and food insecurity: "I decided to forgo [work] and attend clinic […] the voucher relieved me". Patients who borrowed money for care-seeking reported feeling relieved from the burden of indebtedness to others: "I borrow with confidence that I will pay after my appointment." Incentives fostered their autonomy, and enabled them to support others: "I used the money to buy some clothes and Pampers for the children." Participants who were intrinsically motivated to engage in care ("my life depends on the drugs, not the incentive"), and those who mistrusted researchers, reported being less prompted by the incentive itself. For patients not already prioritizing care-seeking, incentives facilitated care engagement through alleviating transport costs, indebtedness and food insecurity, and also supported social role fulfillment. Conditional cash incentives may be an important cue to action to improve progression through the HIV treatment cascade, and contribute to better care retention.
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Affiliation(s)
- Sarah Iguna
- Centre for Microbiology Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Monica Getahun
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, California, United States of America
| | - Jayne Lewis-Kulzer
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, California, United States of America
| | - Gladys Odhiambo
- Centre for Microbiology Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Fridah Adhiambo
- Centre for Microbiology Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Lina Montoya
- Division of Biostatistics, School of Public Health, University of California Berkeley, Berkeley, California, United States of America
| | - Maya L Petersen
- Divisions of Biostatistics and Epidemiology, School of Public Health, University of California Berkeley, Berkeley, California, United States of America
| | - Elizabeth Bukusi
- Centre for Microbiology Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Thomas Odeny
- Department of Medicine, University of Missouri-Kansas City, Kansas City, Missouri, United States of America
| | - Elvin Geng
- Division of Infectious Diseases, Department of Internal Medicine, Washington University, St. Louis, Missouri, United States of America
| | - Carol S Camlin
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, California, United States of America
- Division of Prevention Science, Department of Medicine, University of California, San Francisco, California, United States of America
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Fahey CA, Njau PF, Kelly NK, Mfaume RS, Bradshaw PT, Dow WH, McCoy SI. Durability of effects from short-term economic incentives for clinic attendance among HIV positive adults in Tanzania: long-term follow-up of a randomised controlled trial. BMJ Glob Health 2021; 6:bmjgh-2021-007248. [PMID: 34952856 PMCID: PMC8710859 DOI: 10.1136/bmjgh-2021-007248] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Accepted: 11/19/2021] [Indexed: 12/24/2022] Open
Abstract
Introduction Conditional economic incentives are shown to promote medication adherence across a range of health conditions and settings; however, any long-term harms or benefits from these time-limited interventions remain largely unevaluated. We assessed 2–3 years outcomes from a 6-month incentive programme in Tanzania that originally improved short-term retention in HIV care and medication possession. Methods We traced former participants in a 2013–2016 trial, which randomised 800 food-insecure adults starting HIV treatment at three clinics to receive either usual care (control) or up to 6 months of cash or food transfers (~US$11/month) contingent on timely attendance at monthly clinic appointments. The primary intention-to-treat analysis estimated 24-month and 36-month marginal risk differences (RD) between incentive and control groups for retention in care and all-cause mortality, using multiple imputation for a minority of missing outcomes. We also estimated mortality HRs from time-stratified Cox regression. Results From 3 March 2018 to 19 September 2019, we determined 36-month retention and mortality statuses for 737 (92%) and 700 (88%) participants, respectively. Overall, approximately 660 (83%) participants were in care at 36 months while 43 (5%) had died. There were no differences between groups in retention at 24 months (86.5% intervention vs 84.4% control, RD 2.1, 95% CI −5.2 to 9.3) or 36 months (83.3% vs 77.8%, RD 5.6, –2.7 to 13.8), nor in mortality at either time point. The intervention group had a lower rate of death during the first 18 months (HR 0.27, 95% CI 0.10 to 0.74); mortality was similar thereafter (HR 1.13, 95% CI 0.33 to 3.79). Conclusion These findings confirm that incentives are a safe and effective tool to promote short-term adherence and potentially avert early deaths at the critical time of HIV treatment initiation. Complementary strategies are recommended to sustain lifelong retention in HIV care. Trial registration number NCT01957917
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Affiliation(s)
- Carolyn A Fahey
- Epidemiology, University of California, Berkeley, California, USA .,Epidemiology, University of Washington, Seattle, Washington, USA
| | - Prosper F Njau
- Ministry of Health, Community Development, Gender, Elderly and Children, Dodoma, Tanzania, United Republic of
| | - Nicole K Kelly
- Epidemiology, University of California, Berkeley, California, USA.,Epidemiology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Rashid S Mfaume
- Ministry of Health, Community Development, Gender, Elderly and Children, Dodoma, Tanzania, United Republic of
| | | | - William H Dow
- Health Policy and Management, University of California, Berkeley, California, USA
| | - Sandra I McCoy
- Epidemiology, University of California, Berkeley, California, USA
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Packel L, Fahey C, Kalinjila A, Mnyippembe A, Njau P, McCoy SI. Preparing a financial incentive program to improve retention in HIV care and viral suppression for scale: using an implementation science framework to evaluate an mHealth system in Tanzania. Implement Sci Commun 2021; 2:109. [PMID: 34556176 PMCID: PMC8461932 DOI: 10.1186/s43058-021-00214-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 09/06/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Viral suppression is key to ending the HIV epidemic, yet only 58% of people living with HIV (PLHIV) in sub-Saharan Africa are suppressed. Cash transfers are an effective strategy to improve retention in care, but little is known about optimization of implementation; for example, designing effective programs that integrate into existing clinic workflows. We studied implementation of an mHealth system to deliver cash transfers to support retention. METHODS We conducted a mixed-methods study assessing implementation of an mHealth cash transfer study. This was part of a larger, hybrid implementation-effectiveness randomized controlled trial evaluating cash transfers conditional on visit attendance for viral suppression among Tanzanian PLHIV initiating ART. An mHealth system using fingerprint identification and mobile payments was used to automatically disburse mobile money to eligible PLHIV. We used Proctor's framework, assessing implementation of the mHealth system from the perspectives of PLHIV and clinicians. We analyzed mHealth system data and conducted surveys (n = 530) and in-depth interviews (n = 25) with PLHIV, clinic and pharmacy staff (n = 10), and structured clinic observations (n = 2293 visits). RESULTS One thousand six hundred fifty-one cash transfers were delivered to 346 PLHIV in the cash arms, 78% through mobile money. Among those in the cash arms, 81% registered their mobile money account with the mHealth system by study end, signaling high adoption. While acceptability for fingerprinting and mobile payments was high among PLHIV, interviews revealed mixed views: some had privacy concerns while others felt the system was secure and accurate, and provided some legitimacy to the clinical visits. Pharmacists praised system efficiency, but concerns about duplicative recordkeeping and added work arose. Clinic staff voiced excitement for the system's potential to bring the cash program to all patients and simplify workflows; yet concerns about multiple systems, staffing, and intermittent connectivity tempered enthusiasm, highlighting structural issues beyond program scope. Structured observations revealed a steep learning curve; repeat fingerprint scans and manual entry declined as the system improved. CONCLUSIONS Biometric identification and mobile payments were acceptable to most patients and staff. Fingerprinting encountered some feasibility limitations in the first months of testing; however, mobile payments were highly successful. Biometric identification and mobile payments may provide a scalable mechanism to improve patient tracking and efficiently implement financial incentives in low-resource settings. TRIAL REGISTRATION Name of the registry: clinicaltrials.gov Trial registration number: NCT03351556 Date of registration: 11/24/2017 Checklists: StaRI (included with submission). Note CONSORT for cluster-randomized trials was used for the main trial but is not directly applicable to this manuscript.
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Affiliation(s)
- Laura Packel
- School of Public Health, University of California Berkeley, Berkeley, CA, USA.
| | - Carolyn Fahey
- School of Public Health, University of California Berkeley, Berkeley, CA, USA
| | | | | | - Prosper Njau
- Health for a Prosperous Nation, Dar es Salaam, Tanzania.,National AIDS Control Programme, Ministry of Health, Community Development, Gender, Elderly, and Children, Dodoma, Tanzania
| | - Sandra I McCoy
- School of Public Health, University of California Berkeley, Berkeley, CA, USA
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Packel L, Njau P, Fahey C, Ramadhani A, Dow WH, Jewell NP, McCoy S. Optimizing the efficiency and implementation of cash transfers to improve adherence to antiretroviral therapy: study protocol for a cluster randomized controlled trial. Trials 2020; 21:963. [PMID: 33228757 PMCID: PMC7684892 DOI: 10.1186/s13063-020-04899-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 11/12/2020] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Antiretroviral therapy (ART) for HIV, taken daily, is an effective strategy to clinically suppress the virus, providing the dual benefit of improved survival and vastly decreasing the risk of transmission. However, this highly effective intervention has not yet reached all who could benefit. Cash transfers are increasingly recognized as an effective strategy to motivate behavior change and improve HIV care and treatment outcomes, including engagement in HIV care and adherence to ART. Despite a growing evidence base and strong theoretical foundation for the cash transfer approach, key questions remain. To address these questions and begin to bridge the "know-do gap" with respect to cash transfers, our team is employing an implementation science approach to iterative development of an incentive-based intervention to promote ART uptake and adherence among people living with HIV (PLHIV) in the Lake Zone region, Tanzania. METHODS We will conduct a type I hybrid implementation-effectiveness trial to test the effectiveness of a cash transfer intervention on the outcome of HIV viral suppression, and concurrently examine the potential for real-world implementation with a mobile health technology (mHealth) system. Specifically, our team will expand the intervention to 32 clinics and enroll 1984 PLHIV to (a) evaluate its effectiveness by conducting a cluster randomized controlled trial with clinics as the unit of randomization and 12-month viral suppression as the primary outcome and (b) evaluate the implementation challenges and successes at multiple levels (patient, provider, clinic). DISCUSSION This trial will provide evidence not only about the real-world effectiveness of cash transfers for retention in HIV care and viral suppression, but also on the implementation challenges and successes that will facilitate or hinder wider scale-up within Tanzania and beyond. TRIAL REGISTRATION ClinicalTrials.gov NCT04201353 . Registered on December 17, 2019.
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Affiliation(s)
- Laura Packel
- School of Public Health, Division of Epidemiology, University of California, Berkeley, 2121 Berkeley Way, 5th Floor, Berkeley, CA 94720 USA
| | - Prosper Njau
- Strategic Information and Research Unit, National AIDS Control Program (NACP), Ministry of Health, Community Development, Gender, Elderly, and Children, Dar es Salaam, Tanzania
| | - Carolyn Fahey
- School of Public Health, Division of Epidemiology, University of California, Berkeley, 2121 Berkeley Way, 5th Floor, Berkeley, CA 94720 USA
| | - Angela Ramadhani
- National AIDS Control Programme (NACP), Ministry of Health, Community Development, Gender, Elderly, and Children, Dar es Salaam, Tanzania
| | - William H. Dow
- School of Public Health, Division of Health Policy and Management, University of California, Berkeley, 2121 Berkeley Way, 5th Floor, Berkeley, CA 94720 USA
| | - Nicholas P. Jewell
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, Keppel Street, Bloomsbury, London, WC1E 7HT UK
- School of Public Health Biostatistics Division & Department of Statistics, University of California, Berkeley, 2121 Berkeley Way, 5th Floor, Berkeley, CA 94720 USA
| | - Sandra McCoy
- School of Public Health, Division of Epidemiology, University of California, Berkeley, 2121 Berkeley Way, 5th Floor, Berkeley, CA 94720 USA
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Katumba RGN, Sensoy Bahar O, Johnson KJ, Ssewamala FM. Cancer in Youth Living With HIV (YLWHIV): A Narrative Review of the Access to Oncological Services Among YLWHIV and the Role of Economic Strengthening in Child Health. Front Public Health 2020; 8:409. [PMID: 32923421 PMCID: PMC7457003 DOI: 10.3389/fpubh.2020.00409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 07/09/2020] [Indexed: 12/02/2022] Open
Abstract
Youth Living with HIV/AIDS (YLWHIV) have a higher risk of developing immunodeficiency related illnesses including certain cancers than their general population counterparts of the same age. This narrative review of current available literature describes factors associated with pediatric access to oncological services, and the role economic strengthening could play in improving health outcomes for this vulnerable population. Findings suggest that both HIV-infected and -uninfected children living in low and middle-income countries struggle with access and adherence to cancer treatment and care. Cost of treatment is a major barrier to access and adherence. Asset-building savings programs may increase financial security and subsequently result in better health outcomes although they have not been utilized to improve access to cancer treatment.
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Affiliation(s)
- Ruth G N Katumba
- School of Medicine, Washington University in St. Louis, St. Louis, MO, United States
| | - Ozge Sensoy Bahar
- Brown School, Washington University in St. Louis, St. Louis, MO, United States
| | - Kimberly J Johnson
- Brown School, Washington University in St. Louis, St. Louis, MO, United States
| | - Fred M Ssewamala
- Brown School, Washington University in St. Louis, St. Louis, MO, United States
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Jennings Mayo-Wilson L, Devoto B, Coleman J, Mukasa B, Shelton A, MacCarthy S, Saya U, Chemusto H, Linnemayr S. Habit formation in support of antiretroviral medication adherence in clinic-enrolled HIV-infected adults: a qualitative assessment using free-listing and unstructured interviewing in Kampala, Uganda. AIDS Res Ther 2020; 17:30. [PMID: 32513192 PMCID: PMC7278190 DOI: 10.1186/s12981-020-00283-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 05/15/2020] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Despite initial high motivation, individuals receiving antiretroviral therapy (ART) for several years may experience incomplete adherence over time, increasing their risk of HIV-related morbidity and mortality. Habits, defined as automatic and regular practices, do not rely on conscious effort, and may therefore support high long-term ART adherence. METHODS This qualitative study contributes to the evidence on how clients with adherence problems remember and form habits to take ART medications. Free-listing and unstructured interviewing were used among 42 clinic-enrolled adults in Kampala, Uganda who were receiving ART and participating in a randomized clinical trial for treatment adherence (clinicaltrials.gov: NCT03494777). Data were coded and analyzed using inductive content analysis. RESULTS Findings indicated that clients' most routine habits (eating, bathing, sleeping) did not always occur at the same time or place, making it difficult to reliably link to pill-taking times. Efforts to improve ART habits included having a relative to ask about pill-taking, re-packaging medications, leaving medications in view, using alarms, carrying water, or linking pill-taking to radio/prayer schedules. Reported challenges were adhering to ART schedules during changing employment hours, social activities, and travel. CONCLUSION While habit-forming interventions have the potential to improve ART adherence, targeting treatment-mature clients' existing routines may be crucial in this population.
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Affiliation(s)
- Larissa Jennings Mayo-Wilson
- Indiana University School of Public Health, Department of Applied Health Science, Center for Sexual Health Promotion, 1025 E. 7th Street, Bloomington, IN USA
- Johns Hopkins Bloomberg School of Public Health, Department of International Health, Social and Behavioral Interventions Program, 615 N. Wolfe Street, Baltimore, MD USA
| | - Bianca Devoto
- Johns Hopkins Bloomberg School of Public Health, Department of International Health, Social and Behavioral Interventions Program, 615 N. Wolfe Street, Baltimore, MD USA
| | - Jessica Coleman
- Johns Hopkins Bloomberg School of Public Health, Department of International Health, Social and Behavioral Interventions Program, 615 N. Wolfe Street, Baltimore, MD USA
| | - Barbara Mukasa
- Mildmay Uganda, Mildmay Hospital and Institute of Health Sciences, Box 24985, Kampala, Uganda
| | - Angela Shelton
- Johns Hopkins Bloomberg School of Public Health, Department of International Health, Social and Behavioral Interventions Program, 615 N. Wolfe Street, Baltimore, MD USA
| | | | - Uzaib Saya
- RAND Corporation, 1776 Main Street, Santa Monica, CA USA
| | - Harriet Chemusto
- Mildmay Uganda, Mildmay Hospital and Institute of Health Sciences, Box 24985, Kampala, Uganda
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Implementation Science Using Proctor's Framework and an Adaptation of the Multiphase Optimization Strategy: Optimizing a Financial Incentive Intervention for HIV Treatment Adherence in Tanzania. J Acquir Immune Defic Syndr 2020; 82 Suppl 3:S332-S338. [PMID: 31764271 DOI: 10.1097/qai.0000000000002196] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Ambitious targets have been set to end the HIV epidemic by 2030. Such targets assume that tools to end HIV exist and are successfully being deployed across populations, albeit unequally. Implementation science approaches are needed to understand the drivers of disparities and how to bring effective interventions to those most in need. We describe a hybrid implementation science approach, adapting a strategy to facilitate retention and viral suppression (VS) among people living with HIV/AIDS in Tanzania. METHODS/DESIGN We used Proctor framework and the multiphase optimization strategy to optimize a cash transfer to improve antiretroviral therapy adherence and VS among people living with HIV/AIDS in Tanzania. This involved 3 trials. The first trial tested the efficacy of cash and food assistance compared with the standard of care in improving antiretroviral therapy adherence among treatment initiators. Cash transfers were superior to the standard of care and noninferior, less expensive, and logistically simpler to implement compared with food. The second trial is dose-finding: identifying the optimal amount of cash for a 20% improvement in VS at 6 months. Before this, components were simplified to maximize reach, align with local policies, and reduce staff time. We assessed implementation science constructs to understand barriers to uptake and sustainability. Trial 3 is a cluster randomized controlled trial, testing the effectiveness of the optimized intervention in multiple settings. DISCUSSION/IMPLICATIONS Our process illustrates the utility of applying multiple implementation science frameworks to arrive at an optimal implementation strategy to bridge the know-do gap with data to show efficacy and maximum potential for scalability and sustainability.
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Hunter LA, Prata N, Eskenazi B, Njau PF, McCoy SI. Transportation cost as a barrier to contraceptive use among women initiating treatment for HIV in Tanzania. AIDS Care 2020; 33:206-213. [PMID: 32372660 DOI: 10.1080/09540121.2020.1758613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Transportation cost is a barrier to HIV treatment, yet no studies have examined its association with contraceptive use among women living with HIV. We analyzed cross-sectional data from women attending three public healthcare facilities in Shinyanga, Tanzania where they initiated antiretroviral therapy for HIV infection in the previous 90 days; all facilities offered free contraception. Women self-reported current contraceptive use and the round-trip cost of transportation to the facility. Among 421 women aged 18-49, 86 (20.4%) were using any modern contraceptive method, of which half were using modern methods other than condoms. Women who paid more than 2,000 Tanzanian shillings for transportation had a significantly lower prevalence of any modern method use than women who paid nothing (9.1% vs. 21.3%; adjusted difference: -12.9; 95% confidence interval: -21.3, -4.4). A similar difference was observed for non-condom modern method use. We conclude that high transportation cost may impede contraceptive use even among women accessing HIV treatment.
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Affiliation(s)
- Lauren A Hunter
- School of Public Health, University of California, Berkeley, CA, USA
| | - Ndola Prata
- School of Public Health, University of California, Berkeley, CA, USA
| | - Brenda Eskenazi
- School of Public Health, University of California, Berkeley, CA, USA
| | - Prosper F Njau
- Prevention of Mother-to-Child HIV Transmission Programme, Ministry of Health, Community Development, Gender, Elderly, and Children, Dar es Salaam, Tanzania
| | - Sandra I McCoy
- School of Public Health, University of California, Berkeley, CA, USA
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Galárraga O, Enimil A, Bosomtwe D, Cao W, Barker DH. Group-based economic incentives to improve adherence to antiretroviral therapy among youth living with HIV: safety and preliminary efficacy from a pilot trial. VULNERABLE CHILDREN AND YOUTH STUDIES 2019; 15:257-268. [PMID: 33281920 PMCID: PMC7717062 DOI: 10.1080/17450128.2019.1709678] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 12/23/2019] [Indexed: 06/12/2023]
Abstract
Poor adherence to antiretroviral therapy (ART) has significant consequences for adolescents. Conditional economic incentives (CEI) is an approach that may help address this challenge. This study evaluated the safety and preliminary efficacy of a group-based CEI program for ART adherence improvement among a sample of adolescents living in Ghana. A total of 35 adolescents (mean age: 14.7 years) on ART, though still with detectable viral load, were recruited from an HIV clinic and divided into 5 balanced groups to participate in peer-led group-based CEI activities during routine clinic visits. Four assessments were conducted across four visits at baseline and 3-, 6-, and 9-month follow-up, respectively. Main outcomes were ART adherence and viral load. Linear mixed models and thematic analysis were used for data analyses. The majority (91.4%) of the participants attended all four intervention activities. Participants reported missing an average of 1.06, 0.50, 0.91, 0.55 doses of ART in the past 7 days at baseline, 3-, 6-, and 9-month assessments, respectively. Most viral loads were ≥5,000 copies/ml at both baseline (68.6%) and 6-month assessments (54.3%). The incentive was divided between individual compensation for attending clinic and completing the assessment ($5 each, $20 in total) and a group-based compensation valued at $40 that was distributed during the 9-month assessment according to average group attendance (A≥90%, B≥75%, C≥60%, D<60%) and group-average viral load (A=undetectable, B=50-499, C=500-4999, D≥5,000). The mean earnings for the participants was $46.70 (77.8% of possible earning). Qualitative data suggested that the CEI helped ART adherence through gaining personal and group benefits. Participants reported no teasing, bullying, or other undesirable behaviors from group members. They liked getting money for attending clinics/group meetings and obtaining undetectable viral load. We concluded that a group-based CEI was safe and had the potential to improve ART adherence and reduce viral load among Ghanaian adolescents.
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Affiliation(s)
- Omar Galárraga
- Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, United States
| | - Anthony Enimil
- Directorate of Child Health, Komfo Anokye Teaching Hospital, Kumasi, Ghana
- Department of Child Health, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Dennis Bosomtwe
- Directorate of Child Health, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Wangnan Cao
- Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, United States
| | - David H. Barker
- Department of Psychiatry, Rhode Island Hospital, Providence, United States
- Department of Psychiatry and Human Behavior, Alpert Medical School, Brown University, Providence, United States
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Bor J, Thirumurthy H. Bridging the Efficacy-Effectiveness Gap in HIV Programs: Lessons From Economics. J Acquir Immune Defic Syndr 2019; 82 Suppl 3:S183-S191. [PMID: 31764253 PMCID: PMC7388866 DOI: 10.1097/qai.0000000000002201] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Bridging the efficacy-effectiveness gap in HIV prevention and treatment requires policies that account for human behavior. SETTING Worldwide. METHODS We conducted a narrative review of the literature on HIV in the field of economics, identified common themes within the literature, and identified lessons for implementation science. RESULTS The reviewed studies illustrate how behaviors are shaped by perceived costs and benefits across a wide range of health and nonhealth domains, how structural constraints shape decision-making, how information interventions can still be effective in the epidemic's fourth decade, and how lessons from behavioral economics can be used to improve intervention effectiveness. CONCLUSION Economics provides theoretical insights and empirical methods that can guide HIV implementation science.
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Affiliation(s)
- Jacob Bor
- Department of Global Health, Boston University, Boston, MA
| | - Harsha Thirumurthy
- Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA
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Effects of short-term cash and food incentives on food insecurity and nutrition among HIV-infected adults in Tanzania. AIDS 2019; 33:515-524. [PMID: 30325776 DOI: 10.1097/qad.0000000000002056] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Food insecurity impedes antiretroviral therapy (ART) adherence. We previously demonstrated that short-term cash and food incentives increased ART possession and retention in HIV services in Tanzania. To elucidate potential pathways that led to these achievements, we examined whether incentives also improved food insecurity. DESIGN Three-arm randomized controlled trial. METHODS From 2013 to 2015, 805 food-insecure adult ART initiates (≤90 days) at three clinics were randomized to receive cash or food transfers (∼$11 per month for ≤6 months, conditional on visit attendance) or standard-of-care (SOC) services. We assessed changes from baseline to 6 and 12 months in: food insecurity (severe; access; dietary diversity), nutritional status (body weight; BMI), and work status. Difference-in-differences average treatment effects were estimated using inverse-probability-of-censoring-weighted longitudinal regression models. RESULTS The modified intention-to-treat analysis included 777 nonpregnant participants with 41.6% severe food insecurity. All three study groups experienced improvements from baseline in food insecurity, nutritional status, and work status. After 6 months, severe food insecurity declined within the cash (-31.4% points to 11.5%) and food (-30.3 to 10.4%) groups, but not within the SOC. Relative to the SOC, severe food insecurity decreased by an additional 24.3% points for cash (95% CI -45.0 to -3.5) and 23.3% percent points for food (95% CI -43.8 to -2.7). Neither intervention augmented improvements in severe food insecurity at 12 months, nor food access, dietary diversity, nutritional status, or work status at 6 or 12 months. CONCLUSION Small cash and food transfers provided at treatment initiation may mitigate severe food insecurity. These effects may have facilitated previously observed improvements in ART adherence.
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Bermudez LG, Ssewamala FM, Neilands TB, Lu L, Jennings L, Nakigozi G, Mellins CA, McKay M, Mukasa M. Does Economic Strengthening Improve Viral Suppression Among Adolescents Living with HIV? Results From a Cluster Randomized Trial in Uganda. AIDS Behav 2018; 22:3763-3772. [PMID: 29846836 DOI: 10.1007/s10461-018-2173-7] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
To assess the effect of a savings-led economic empowerment intervention on viral suppression among adolescents living with HIV. Using data from Suubi + Adherence, a longitudinal, cluster randomized trial in southern Uganda (2012-2017), we examine the effect of the intervention on HIV RNA viral load, dichotomized between undetectable (< 40 copies/ml) and detectable (≥ 40 copies/ml). Cluster-adjusted comparisons of means and proportions were used to descriptively analyze changes in viral load between study arms while multi-level modelling was used to estimate treatment efficacy after adjusting for fixed and random effects. At 24-months post intervention initiation, the proportion of virally suppressed participants in the intervention cohort increased tenfold (ΔT2-T0 = + 10.0, p = 0.001) relative to the control group (ΔT2-T0 = + 1.1, p = 0.733). In adjusted mixed models, simple main effects tests identified significantly lower odds of intervention adolescents having a detectable viral load at both 12- and 24-months. Interventions addressing economic insecurity have the potential to bolster health outcomes, such as HIV viral suppression, by improving ART adherence among vulnerable adolescents living in low-resource environments. Further research and policy dialogue on the intersections of financial security and HIV treatment are warranted.
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Affiliation(s)
- Laura Gauer Bermudez
- Columbia University School of Social Work, 1255 Amsterdam Ave., New York, NY, 10027, USA.
| | - Fred M Ssewamala
- George Warren Brown School of Social Work, Washington University in St. Louis, 1 Brookings Drive, St. Louis, MO, 63130, USA
| | - Torsten B Neilands
- School of Medicine, University of California San Francisco, 550 16th Street, San Francisco, CA, 94158, USA
| | - Lily Lu
- Department of Epidemiology, Columbia University Mailman School of Public Health, 722 West 168th Street, New York, NY, 10032, USA
| | - Larissa Jennings
- Department of International Health, Social and Behavioral Interventions Program, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Room E5038, Baltimore, MD, 21205, USA
| | - Gertrude Nakigozi
- Rakai Health Sciences Program, Old Bukoba Road, 279, Kalisizo, Uganda
| | - Claude A Mellins
- HIV Center for Clinical & Behavioral Studies, New York State Psychiatric Institute and Columbia University, 1051 Riverside Dr, New York, NY, 10032, USA
| | - Mary McKay
- George Warren Brown School of Social Work, Washington University in St. Louis, 1 Brookings Drive, St. Louis, MO, 63130, USA
| | - Miriam Mukasa
- International Center for Child Health and Development Field Office, Plot 23 Circular Rd, Masaka, Uganda
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Conserve DF, Muessig KE, Maboko LL, Shirima S, Kilonzo MN, Maman S, Kajula L. Mate Yako Afya Yako: Formative research to develop the Tanzania HIV self-testing education and promotion (Tanzania STEP) project for men. PLoS One 2018; 13:e0202521. [PMID: 30148846 PMCID: PMC6110473 DOI: 10.1371/journal.pone.0202521] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2018] [Accepted: 08/03/2018] [Indexed: 11/22/2022] Open
Abstract
The purpose of this formative research, guided by the Integrated Behavioral Model, was to assess men's attitudes and personal agency towards HIV self-testing (HIVST) and confirmatory HIV testing in order to inform the development of the Tanzania STEP (Self-Testing Education and Promotion) Project, a peer-based HIV self-testing intervention for young men in Tanzania. Qualitative in-depth interviews were conducted with 23 men in Dar es Salaam, Tanzania who socialize in networks locally referred to as "camps". Men reported privacy, confidentiality, and saving time as the primary reasons for their self-testing interest. Most participants had high perceived control and self-efficacy to self-test and seek confirmatory HIV testing. Nevertheless, men reported concerns related to their ability to perform the test and the potential lack of post-test counseling. Specific recommendations for the intervention included providing HIVST education and pre-test counseling, and using mobile health (mHealth) strategies for participants to reach a healthcare professional for further assistance. The findings suggest that while HIVST is highly acceptable among men in Tanzania, future interventions will need to address the challenges that men may face with HIVST before promoting it as an alternative or supplement to facility-based HIV testing.
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Affiliation(s)
- Donaldson F. Conserve
- Department of Health Promotion, Education, and Behavior, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina, United States of America
| | - Kathryn E. Muessig
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | | | - Sylvia Shirima
- Department of Health Promotion, Education, and Behavior, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina, United States of America
| | - Mrema N. Kilonzo
- Department of Psychiatry and Mental Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Suzanne Maman
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Lusajo Kajula
- Department of Psychiatry and Mental Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
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Kadota JL, Fahey CA, Njau PF, Kapologwe N, Padian NS, Dow WH, McCoy SI. The heterogeneous effect of short-term transfers for improving ART adherence among HIV-infected Tanzanian adults. AIDS Care 2018; 30:18-26. [PMID: 30793875 DOI: 10.1080/09540121.2018.1476666] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
A recently concluded randomized study in Tanzania found that short-term conditional cash and food transfers significantly improved HIV-infected patients’ possession of antiretroviral therapy (ART) and reduced patient loss to follow-up (LTFU) (McCoy, S. I., Njau, P. F., Fahey, C., Kapologwe, N., Kadiyala, S., Jewell, N. P., & Padian, N. S. (2017). Cash vs. food assistance to improve adherence to antiretroviral therapy among HIV-infected adults in Tanzania. AIDS, 31(6), 815–825. doi:10.1097/QAD.0000000000001406 ). We examined whether these transfers had differential effects within population subgroups. In the parent study, 805 individuals were randomized to one of three study arms: standard-of-care (SOC) HIV services, food assistance, or cash transfer. We compared achievement of the medication possession ratio (MPR) ≥ 95% at 6 and 12 months and patient LTFU at 12 months between those receiving the SOC and those receiving food or cash (combined). Using a threshold value of p < 0.20 to signal potential effect measure modifiers (EMM), we compared intervention effects, expressed as risk differences (RD), within subgroups characterized by: sex, age, wealth, and time elapsed between HIV diagnosis and ART initiation. Short-term transfers improved 6 and 12-month MPR ≥ 95% and reduced 12-month LTFU in most subgroups. Study results revealed wealth and time elapsed between HIV diagnosis and ART initiation as potential EMMs, with greater effects for 6-month MPR ≥ 95% in the poorest patients (RD: 32, 95% CI: (9, 55)) compared to those wealthier (RD: 16, 95% CI: (5, 27); p = 0.18) and in newly diagnosed individuals (<90 days elapsed since diagnosis) (RD: 25, 95% CI: (13, 36)) compared to those with ≥90 days (RD: 0.3, 95% CI (−17, 18); p = 0.02), patterns which were sustained at 12 months. Results suggest that food and cash transfers may have stronger beneficial effects on ART adherence in the poorest patients. We also provide preliminary data suggesting that targeting interventions at patients more recently diagnosed with HIV may be worthwhile. Larger and longer-term assessments of transfer programs for the improvement of ART adherence and their potential heterogeneity by sub-population are warranted.
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Affiliation(s)
- Jillian L Kadota
- Division of Epidemiology, University of California, Berkeley, CA, USA
| | - Carolyn A Fahey
- Division of Epidemiology, University of California, Berkeley, CA, USA
| | - Prosper F Njau
- Prevention of Mother-to-Child HIV Transmission Programme, Ministry of Health, Community Development, Gender, Elderly, and Children, Dar es Salaam, Tanzania
| | - Ntuli Kapologwe
- Regional Medical Office, Ministry of Health, Community Development, Gender, Elderly, and Children, Shinyanga, Tanzania
| | - Nancy S Padian
- Division of Epidemiology, University of California, Berkeley, CA, USA
| | - William H Dow
- Division of Health Policy and Management, University of California, Berkeley, CA, USA
| | - Sandra I McCoy
- Division of Epidemiology, University of California, Berkeley, CA, USA
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Czaicki NL, Dow WH, Njau PF, McCoy SI. Do incentives undermine intrinsic motivation? Increases in intrinsic motivation within an incentive-based intervention for people living with HIV in Tanzania. PLoS One 2018; 13:e0196616. [PMID: 29902177 PMCID: PMC6002082 DOI: 10.1371/journal.pone.0196616] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2017] [Accepted: 04/15/2018] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Cash and in-kind incentives can improve health outcomes in various settings; however, there is concern that incentives may 'crowd out' intrinsic motivation to engage in beneficial behaviors. We examined this hypothesis in a randomized trial of food and cash incentives for people living with HIV infection in Tanzania. METHODS We analyzed data from 469 individuals randomized to one of three study arms: standard of care, short-term cash transfers, or short-term food assistance. Eligible participants were: 1) ≥18 years old; 2) HIV-infected; 3) food insecure; and 4) initiated antiretroviral therapy (ART) ≤90 days before the study. Food or cash transfers, valued at ~$11 per month and conditional on attending clinic visits, were provided for ≤6 months. Intrinsic motivation was measured at baseline, 6, and 12 months using the autonomous motivation section of the Treatment Self-Regulation Questionnaire (TSRQ). We compared the change in TSRQ score from baseline to 6 and 12 months and the change within study arms. RESULTS The mean intrinsic motivation score was 2.79 at baseline (range: 1-3), 2.91 at 6 months (range: 1-3), and 2.95 at 12 months (range: 2-3), which was 6 months after the incentives had ended. Among all patients, the intrinsic motivation score increased by 0.13 points at 6 months (95% CI (0.09, 0.17), Cohen's d = 0.29) and 0.19 points at 12 months (95% CI (0.14, 0.24), Cohen's d = 0.49). Intrinsic motivation also increased within each study group at 6 months: 0.15 points in the food arm (95% CI (0.09, 0.21), Cohen's d = 0.37), 0.11 points in the cash arm (95% CI (0.05, 0.18), Cohen's d = 0.25), and 0.08 points in the comparison arm (95% CI (-0.03, 0.19), Cohen's d = 0.21); findings were similar at 12 months. Increases in motivation were statistically similar between arms at 6 and 12 months. CONCLUSION Intrinsic motivation for ART adherence increased significantly both overall and within the food and cash incentive arms, even after the incentive period was over. Increases in motivation did not differ by study group. These results suggest that incentive interventions for treatment adherence should not be withheld due to concerns of crowding out intrinsic motivation.
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Affiliation(s)
- Nancy L. Czaicki
- Division of Epidemiology, School of Public Health, University of California Berkeley, Berkeley, CA, United States of America
| | - William H. Dow
- Health Services and Policy Analysis Graduate Group, School of Public Health, University of California Berkeley, Berkeley, CA, United States of America
| | - Prosper F. Njau
- Ministry of Health, Community Development, Gender, Elderly, and Children, Dar es Salaam, Tanzania
| | - Sandra I. McCoy
- Division of Epidemiology, School of Public Health, University of California Berkeley, Berkeley, CA, United States of America
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Towards 90-90-90 Target: Factors Influencing Availability, Access, and Utilization of HIV Services-A Qualitative Study in 19 Ugandan Districts. BIOMED RESEARCH INTERNATIONAL 2018; 2018:9619684. [PMID: 29750175 PMCID: PMC5884295 DOI: 10.1155/2018/9619684] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/03/2017] [Accepted: 02/13/2018] [Indexed: 12/15/2022]
Abstract
Background UNAIDS has set a new target 90-90-90 by 2020. To achieve this target, current programs need to address challenges that limit access, availability, and utilization of HIV testing and treatment services. Therefore, the aim of this study was to identify the barriers that influence access, availability, and utilization of HIV services in rural Uganda within the setting of a large donor funded program. Methods We conducted key informant interviews with stakeholders at the district level, staff of existing HIV/AIDS projects, and health facilities in 19 districts. Data were also collected from focus group discussions comprised of clients presenting for HIV care and treatment. Data were transcribed and analyzed using content analysis. Results. Barriers identified were as follows: (1) drug shortages including antiretroviral drugs at health facilities. Some patients were afraid to start ART because of worrying about shortages; (2) distance and (3) staffing shortages; (4) stigma persistence; (5) lack of social and economic support initiatives that enhance retention in treatment. Conclusions In conclusion, our study has identified several factors that influence access, availability, and utilization of HIV services. Programs need to address drug and staff shortages, HIV stigma, and long distances to health facilities to broaden access and utilization in order to realize the UNAIDS target.
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Wroe EB, Dunbar EL, Kalanga N, Dullie L, Kachimanga C, Mganga A, Herce M, Beste J, Rigodon J, Nazimera L, McBain RK. Delivering comprehensive HIV services across the HIV care continuum: a comparative analysis of survival and progress towards 90-90-90 in rural Malawi. BMJ Glob Health 2018; 3:e000552. [PMID: 29564158 PMCID: PMC5859809 DOI: 10.1136/bmjgh-2017-000552] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Revised: 11/26/2017] [Accepted: 11/27/2017] [Indexed: 11/16/2022] Open
Abstract
Introduction Partners In Health and the Malawi Ministry of Health collaborate on comprehensive HIV services in Neno, Malawi, featuring community health workers, interventions addressing social determinants of health and health systems strengthening. We conducted an observational study to describe the HIV care continuum in Neno and to compare facility-level HIV outcomes against health facilities nationally. Methods We compared facility-level outcomes in Neno (n=13) with all other districts (n=682) from 2013 to 2015 using mixed-effects linear regression modelling. We selected four outcomes that are practically useful and roughly mapped on to the 90-90-90 targets: facility-based HIV screenings relative to population, new antiretroviral therapy (ART)enrolments relative to population, 1-year survival rates and per cent retained in care at 1 year. Results In 2013, the average number of HIV tests performed, as a per cent of the adult population, was 11.75%, while the average newly enrolled patients was 10.03%. Percent receiving testing increased by 4.23% over 3 years (P<0.001, 95% CI 2.98% to 5.49%), while percent enrolled did not change (P=0.28). These results did not differ between Neno and other districts (P=0.52), despite Neno having a higher proportion of expected patients enrolled. In 2013, the average ART 1-year survival was 80.41% nationally and 91.51% in Neno, which is 11.10% higher (P=0.002, 95% CI 4.13% to 18.07%). One-year survival declined by 1.75% from 2013 to 2015 (P<0.001, 95% CI −2.61% to −0.89%); this was similar in Neno (P=0.83). Facility-level 1-year retention was 85.43% nationally in 2013 (P<0.001, 95% CI 84.2% to 86.62%) and 12.07% higher at 97.50% in Neno (P=0.001, 95% CI 5.08% to19.05%). Retention declined by 2.92% (P<0.001, 95% CI −3.69% to −2.14%) between 2013 and 2015, both nationally and in Neno. Conclusion The Neno HIV programme demonstrated significantly higher survival and retention rates compared with all other districts in Malawi. Incorporating community health workers, strengthening health systems and addressing social determinants of health within the HIV programme may help Malawi and other countries accelerate progress towards 90-90-90.
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Affiliation(s)
| | | | - Noel Kalanga
- Health Systems and Policy, College of Medicine, Blantyre, Malawi
| | | | | | - Andrew Mganga
- Department of HIV and AIDS, Ministry of Health, Lilongwe, Malawi
| | - Michael Herce
- Division of Infectious Diseases, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | | | - Jonas Rigodon
- Haiti Delegation, American Red Cross, Port-au-Prince, Haiti
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Evangeli M, Ferris K, Kenney NM, Baker LLE, Jones B, Wroe AL. A systematic review of psychological correlates of HIV testing intention. AIDS Care 2018; 30:18-26. [PMID: 28685584 DOI: 10.1080/09540121.2017.1344351] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2016] [Accepted: 06/15/2017] [Indexed: 12/27/2022]
Abstract
Undiagnosed HIV infection is associated with onward HIV transmission and delays in accessing HIV care and treatment. As a significant proportion of HIV tests are self-initiated, it is important to assess correlates of the intention to test for HIV. Psychological correlates of HIV testing intention are more likely to be the feasible target of interventions than structural determinants. A systematic review of psychological correlates of HIV testing intention was conducted. Twenty studies were included in the review, covering a range of populations and geographical regions. The most commonly assessed variables were HIV risk perception and HIV knowledge rather than HIV test-specific psychological factors. There was evidence that HIV risk perception and pro-testing attitudes were consistently associated with HIV testing intention across a number of studies. There is a need for longitudinal designs, including experimental studies, allowing for more confident casual inferences to be made. Theoretical, research and practice implications are outlined.
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Affiliation(s)
- Michael Evangeli
- a Department of Psychology , Royal Holloway University of London , Egham , UK
| | - Krissie Ferris
- a Department of Psychology , Royal Holloway University of London , Egham , UK
| | - Natalie M Kenney
- a Department of Psychology , Royal Holloway University of London , Egham , UK
| | - Laura L E Baker
- a Department of Psychology , Royal Holloway University of London , Egham , UK
| | - Bethanie Jones
- a Department of Psychology , Royal Holloway University of London , Egham , UK
| | - Abigail L Wroe
- a Department of Psychology , Royal Holloway University of London , Egham , UK
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19
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Sunguya BF, Ulenga NK, Siril H, Puryear S, Aris E, Mtisi E, Tarimo E, Urassa DP, Fawzi W, Mugusi F. High magnitude of under nutrition among HIV infected adults who have not started ART in Tanzania--a call to include nutrition care and treatment in the test and treat model. BMC Nutr 2017; 3:58. [PMID: 32153838 PMCID: PMC7050693 DOI: 10.1186/s40795-017-0180-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 07/06/2017] [Indexed: 01/17/2023] Open
Abstract
Background Undernutrition among people living with HIV (PLWHIV) can be ameliorated if nutrition specific and sensitive interventions are integrated into their HIV care and treatment centers (CTC). Integrated care is lacking despite expansion of antiretroviral therapy (ART) coverage, representing a substantial missed opportunity. This research aims to examine nutritional status and associated risk factors among HIV-positive adults prior to ART initiation in Tanzania in order to characterize existing gaps and inform early integration of nutrition care into CTC. Methods We analyzed data from 3993 pre-ART adults living with HIV enrolled in CTCs within the Trial of Vitamin (TOV3) and progression of HIV/AIDS study in Dar es salaam, Tanzania. The primary outcome for this analysis was undernutrition, measured as body mass index (BMI) below 18.5 kg/m2. We conducted descriptive analyses of baseline characteristics and utilized multiple logistic regression to determine independent factors associated with pre-ART undernutrition. Results Undernutrition was prevalent in about 27.7% of pre-ART adults, with a significantly higher magnitude among males compared to females (30% vs. 26.6%, p < 0.025). Severe undernutrition (BMI < 16.0 kg/m2) was prevalent in one in four persons, with a trend toward higher magnitudes among females (26.2% vs. 21.1% p = 0.123). Undernutrition was also more prevalent among younger adults (p < 0.001), those with lower wealth quintiles (p = 0.003), and those with advanced HIV clinical stage (p < 0.001). Pre-ART adults presented with poor feeding practices, hallmarked by low dietary diversity scores and infrequent consumption of proteins, vegetables, and fruits. After adjusting for confounders and important co-variates, pre-ART undernutrition was associated with younger age, low wealth indices, advanced clinical stage, and low dietary diversity. Conclusions One in every four pre-ART PLWHIV presented with undernutrition in Dar es salaam, Tanzania. Risk factors for undernourishment included younger age, lower household income, advanced HIV clinical stage, and lower dietary diversity score. Knowledge of the prevalence and prevailing risk factors for undernutrition among pre-ART PLWHIV should guide targeted, early integration of nutrition interventions into routine HIV care and treatment in high-prevalence, low-income settings such as Tanzania.
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Affiliation(s)
- Bruno F Sunguya
- 1Afya Bora Consortium, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, 9, United Nations Road, Upanga West, Dar es salaam, Tanzania
| | - Nzovu K Ulenga
- 2Management and Development for Health, Dar es salaam, Tanzania
| | - Hellen Siril
- 2Management and Development for Health, Dar es salaam, Tanzania
| | - Sarah Puryear
- 4Department of Global Health, University of Washington, Seattle, WA USA
| | - Eric Aris
- 2Management and Development for Health, Dar es salaam, Tanzania
| | | | - Edith Tarimo
- 1Afya Bora Consortium, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, 9, United Nations Road, Upanga West, Dar es salaam, Tanzania
| | - David P Urassa
- 1Afya Bora Consortium, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, 9, United Nations Road, Upanga West, Dar es salaam, Tanzania
| | - Wafaie Fawzi
- 5Departments of Global Health and Population, Nutrition, and Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA USA
| | - Ferdnand Mugusi
- 1Afya Bora Consortium, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, 9, United Nations Road, Upanga West, Dar es salaam, Tanzania
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Beyrer C, Shisana O, Baral SD, Milsana K, Mayer KH, Pozniak A, Walker BD, Mboup S, Sohn AH, Serwadda D, Rees H, Dvoriak S, Warren M, Thiam S, El-Sadr WM, Hospital X, Ryan O, Thomson N, Bekker LG. The science of Durban, AIDS 2016. J Int AIDS Soc 2017; 20:21781. [PMID: 28692209 PMCID: PMC5515038 DOI: 10.7448/ias.20.1.21781] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Accepted: 04/25/2017] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION The science presented at the 21st International AIDS Conference in Durban, South Africa, in July 2016, addressed the state of the field across basic, clinical, prevention, law and policy and implementation science. METHODS AND RESULTS The AIDS response has seen remarkable achievements in scientific advances, in translation of those advances into prevention, treatment and care for affected individuals and communities, and in large scale implementation - reaching 18 million people with antiviral therapy by mid-year 2016. Yet incident HIV infections in adults remain stubbornly stable and are increasing in some regions and among adolescents and adults in some key populations, challenging current science, policy and programming. There have been important advances in both preventive vaccines and in cure research, but both areas require ongoing investment and innovation. Clinical research has flourished with new agents, regimens, delivery modes and diagnostics but has been challenged by aging and increasingly complex patient populations, long-term adherence challenges, co-infections and co-morbidities, and unresolved issues in TB management and epidemic control. It is an extraordinary period of innovation in prevention, yet the promise of new tools and combination approaches have yet to deliver epidemic HIV control. CONCLUSIONS Proven interventions, most notably pre-exposure prophylaxis, PrEP, have been limited in rollout and impact. Treatment as prevention has the promise to improve clinical outcomes but remains uncertain as a prevention tool to reduce population-level HIV incidence. The improvement of legal, policy and human rights environments for those most at risk for HIV acquisition and most at risk for lack of access to essential services; sexual and gender minorities, sex workers of all genders, people who inject drugs, and prisoners and detainees remain among the greatest unmet needs in HIV/AIDS. Failure to do better for these individuals and communities could undermine the HIV response.
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Affiliation(s)
- Chris Beyrer
- Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- International AIDS Society, Geneva, Switzerland
| | | | - Stefan D. Baral
- Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Koleka Milsana
- Department of Medicine, University of KwaZulua Natal, Durban, South Africa
| | - Kenneth H. Mayer
- Department of Medicine, Harvard Medical School, Fenway Community Health Center, Boston, USA
| | - Anton Pozniak
- Department of Medicine, Chelsea and Westminster Hospital, London, UK
| | - Bruce D. Walker
- Ragon Institute of MGH, MIT, and Harvard, Cambridge, MA, USA
| | - Souleman Mboup
- Institut de Recherche en Santé, de Surveillance Epidemiologique et de Formations, Dakar, Senegal
| | - Annette H. Sohn
- TREAT Asia, amfAR – The Foundation for AIDS Research, Bangkok, Thailand
| | - David Serwadda
- Department of Epidemiology, Makerere University School of Public Health Kampala, Uganda
| | - Helen Rees
- Wits RHI, University of the Witwatersrand, Johannesburg, South Africa
| | - Sergii Dvoriak
- Ukrainian Institute on Public Health Policy, Kiev, Ukraine
| | | | - Safiatou Thiam
- Department of Health, National AIDS Council of Senegal, Dakar
| | - Wafaa M. El-Sadr
- Mailman School of Public Health, ICAP at Columbia University, New York, NY, USA
| | - Xavier Hospital
- Department of Health, UNESCO Regional Office in Dakar, Dakar, Senegal
| | - Owen Ryan
- International AIDS Society, Geneva, Switzerland
| | - Nicolas Thomson
- Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Linda-Gail Bekker
- International AIDS Society, Geneva, Switzerland
- Desmond Tutu HIV Research Foundation, University of Cape Town, Cape Town, South Africa
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Czaicki NL, Mnyippembe A, Blodgett M, Njau P, McCoy SI. It helps me live, sends my children to school, and feeds me: a qualitative study of how food and cash incentives may improve adherence to treatment and care among adults living with HIV in Tanzania. AIDS Care 2017; 29:876-884. [PMID: 28397527 DOI: 10.1080/09540121.2017.1287340] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Financial and in-kind incentives have been shown to improve outcomes along the HIV care cascade, however the potential mechanismsthrough which they work remain unclear. To identify the pathways through which incentives improve retention in care and adherence to antiretroviral therapy (ART), we conducted a qualitative study with participants in a trial evaluating conditional food and cash incentives for HIV-positive food insecure adults in Shinyanga, Tanzania. We found that the incentives acted through three pathways to potentially increase retention in care and adherence to ART: (1) addressing competing needs and offsetting opportunity costs associated with clinic attendance, (2) alleviating stress associated with attending clinic and meeting basic needs, and (3) by potentially increasing motivation. Participants did not report any harmful events associated with the incentives, but reported myriad beneficial effects on household welfare. Understanding how incentives are used and how they impact outcomes can improve the design of future interventions.
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Affiliation(s)
- Nancy L Czaicki
- a School of Public Health, Division of Epidemiology , University of California , Berkeley , USA
| | - Agatha Mnyippembe
- b Regional Medical Office, Ministry of Health, Community Development, Gender, Elderly, and Children , Shinyanga , Tanzania
| | - Madeline Blodgett
- a School of Public Health, Division of Epidemiology , University of California , Berkeley , USA.,c The Sea Change Program , Berkeley , CA , USA
| | - Prosper Njau
- d Prevention of Mother-to-Child HIV Transmission Programme, Ministry of Health, Community Development, Gender, Elderly, and Children , Dar es Salaam , Tanzania
| | - Sandra I McCoy
- a School of Public Health, Division of Epidemiology , University of California , Berkeley , USA
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McCoy SI, Njau PF, Fahey C, Kapologwe N, Kadiyala S, Jewell NP, Dow WH, Padian NS. Cash vs. food assistance to improve adherence to antiretroviral therapy among HIV-infected adults in Tanzania. AIDS 2017; 31:815-825. [PMID: 28107221 PMCID: PMC5342932 DOI: 10.1097/qad.0000000000001406] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVE We evaluated the effectiveness of short-term cash and food assistance to improve adherence to antiretroviral therapy (ART) and retention in care among people living with HIV in Tanzania. METHODS At three clinics, 805 participants were randomized to three groups in a 3 : 3 : 1 ratio, stratified by site : nutrition assessment and counseling (NAC) and cash transfers (∼$11/month, n = 347), NAC and food baskets (n = 345), and NAC-only (comparison group, n = 113, clinicaltrials.gov NCT01957917). Eligible people living with HIV were at least 18 years, initiated ART 90 days or less prior, and food insecure. Cash or food was provided for 6 or less consecutive months, conditional on visit attendance. The primary outcome was medication possession ratio (MPR ≥ 95%) at 6 months. Secondary outcomes were appointment attendance and loss to follow-up (LTFU) at 6 and 12 months. RESULTS The primary intent-to-treat analysis included 800 participants. Achievement of MPR ≥ 95% at 6 months was higher in the NAC + cash group compared with NAC-only (85.0 vs. 63.4%), a 21.6 percentage point difference [95% confidence interval (CI): 9.8, 33.4, P < 0.01]. MPR ≥ 95% was also significantly higher in the NAC + food group vs. NAC-only (difference = 15.8, 95% CI: 3.8, 27.9, P < 0.01). When directly compared, MPR ≥ 95% was similar in the NAC + cash and NAC + food groups (difference = 5.7, 95% CI: -1.2, 12.7, P = 0.15). Compared with NAC-only, appointment attendance and LTFU were significantly higher in both the NAC + cash and NAC + food groups at 6 months. At 12 months, the effect of NAC + cash, but not NAC + food, on MPR ≥ 95% and retention was sustained. CONCLUSION Short-term conditional cash and food assistance improves ART possession and appointment attendance and reduces LTFU among food-insecure ART initiates in Tanzania.
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Affiliation(s)
- Sandra I McCoy
- aDivision of Epidemiology, University of California, Berkeley, California, USA bPrevention of Mother-to-Child HIV Transmission Programme, Ministry of Health, Community Development, Gender, Elderly, and Children, Dar es Salaam cRegional Medical Office, Ministry of Health, Community Development, Gender, Equity, and Children, Shinyanga, Tanzania dFaculty of Epidemiology and Population Health, Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK eDivision of Biostatistics fDivision of Health Policy and Management, University of California, Berkeley, California, USA
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Czaicki NL, Holmes CB, Sikazwe I, Bolton C, Savory T, wa Mwanza M, Moyo C, Padian NS, Geng EH. Nonadherence to antiretroviral therapy among HIV-infected patients in Zambia is concentrated among a minority of patients and is highly variable across clinics. AIDS 2017; 31:689-696. [PMID: 28225707 DOI: 10.1097/qad.0000000000001347] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The distribution of adherence to antiretroviral therapy (ART) can indicates whether barriers are concentrated or more distributed. We quantified the medication possession ratio (MPR) and characterized the distribution of medication nonpossession in a network of clinics in Zambia to identify 'hotspots' and predictors of poorer adherence. METHODS We analyzed a population of adults on ART for more than 3 months who made at least one clinic visit between 1 January 2013 and 28 February 2015. Pharmacy refill and clinical information were obtained through the electronic medical record system used in routine care. We constructed a Lorenz curve to visualize the distribution of poor adherence and used a multilevel logistic regression model to examine factors associated with MPR. RESULTS Among 131 767 patients in 56 clinics [64% women, median age 34 years (interquartile range (IQR) 29-41), median CD4 cell count at ART initiation 351 cells/μl (IQR 220-517)], the median MPR was 85.8% (IQR 70.8-96.8). During months 7-12 on ART, 45.6% of patients had 100% MPR and 10.5% accounted for 50% of medication nonpossession. Across clinics, median MPR ranged from 49.1 to 98.5, and clinic accounted for 12% of the variability in adherence after adjusting for individual and clinic-level characteristics. CONCLUSION A small fraction of patients account for the majority of days of medication nonpossession. Further characterization of these subpopulations is needed to target interventions. Clinic also accounted for much variability in MPR. Health systems interventions targeting clinic 'hot spots' may represent an efficient use of resources to improve ART adherence.
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