1
|
Meque I, Herrera N, Gill MM, Guilaze R, Nhangave A, Mussá J, Bhatt N, Bonou M, Greenberg L. Consistency of Multi-Month Antiretroviral Therapy Dispensing and Association with Viral Load Coverage among Pediatric Clients Living with HIV in Mozambique. Trop Med Infect Dis 2024; 9:141. [PMID: 39058183 PMCID: PMC11281662 DOI: 10.3390/tropicalmed9070141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Revised: 06/18/2024] [Accepted: 06/19/2024] [Indexed: 07/28/2024] Open
Abstract
With the increase in uptake of multi-month antiretroviral therapy dispensing (MMD) for children, little is known about consistency of MMD receipt over time and its association with virological outcomes. This analysis aims to assess the uptake of 3-month MMD among children, consistent receipt of MMD after uptake, and clinical outcomes following transition to MMD in 16 health facilities in Gaza and Inhambane Provinces. This is a secondary analysis involving children <15 years living with HIV with clinical visits during the period from September 2019 to August 2020. Of 4383 children, 82% ever received MMD (at least one pickup of a 3-month MMD supply) during the study period but only 40% received it consistently (defined as MMD at every visit during the study period). Consistent MMD was most common among older children and children without indications of clinical instability. Overall viral load (VL) coverage was 40% (733/1851). Consistent MMD was significantly associated with lower odds of having a VL (0.78, 95% CI: 0.64-0.95). In conclusion, while receipt of a multi-month supply was common particularly during the early days of the COVID-19 pandemic, only a minority of children received consistent MMD; however, there is a need to ensure children with fewer visits still receive timely VL monitoring.
Collapse
Affiliation(s)
- Ivete Meque
- Elizabeth Glaser Pediatric AIDS Foundation, Maputo, Mozambique; (I.M.)
| | - Nicole Herrera
- Elizabeth Glaser Pediatric AIDS Foundation, Washington, DC 20005, USA
| | - Michelle M. Gill
- Elizabeth Glaser Pediatric AIDS Foundation, Washington, DC 20005, USA
| | - Rui Guilaze
- Elizabeth Glaser Pediatric AIDS Foundation, Maputo, Mozambique; (I.M.)
| | - Amancio Nhangave
- Núcleo de Pesquisa Provincial de Gaza, Provincial Health Directorate, Gaza, Mozambique
| | - Jaciara Mussá
- Núcleo de Investigação Operacional de Inhambane, Provincial Health Directorate, Inhambane, Mozambique
| | - Nilesh Bhatt
- Elizabeth Glaser Pediatric AIDS Foundation, Washington, DC 20005, USA
| | - Mahoudo Bonou
- Elizabeth Glaser Pediatric AIDS Foundation, Maputo, Mozambique; (I.M.)
| | - Lauren Greenberg
- Elizabeth Glaser Pediatric AIDS Foundation, Washington, DC 20005, USA
| |
Collapse
|
2
|
Machumu N, Frumence G, Anaeli A. Facilitators and barriers to optimum uptake of multimonth dispensing of antiretroviral treatment in Morogoro, Tanzania: a qualitative study. BMJ Open 2024; 14:e080434. [PMID: 38890137 PMCID: PMC11191770 DOI: 10.1136/bmjopen-2023-080434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Accepted: 06/11/2024] [Indexed: 06/20/2024] Open
Abstract
OBJECTIVES Aimed at determining facilitators and barriers to optimum uptake of multimonth dispensing (MMD) of antiretroviral treatment (ART). DESIGN Qualitative study conducted through in-depth interviews. SETTING An explorative qualitative approach conducted at three high-volume care and treatment clinics in Morogoro Municipality, Tanzania. PARTICIPANTS Data were collected from a purposefully selected sample of 22 participants. Of them, 9 were healthcare providers and 12 were clients on ART receiving MMD. Audio records from the interviews were transcribed, translated, and thematically analysed. RESULTS Evidence showed that multimonth dispensing can be improved through strengthened health system barriers such as having proper guidelines and involving stakeholders. Other facilitators included service providers' ability to identify eligible clients, fast-tracking of services, quality improvement implementation, peer-to-peer inspiration and clients' satisfaction and awareness. Identified barriers to effective multimonth dispensing included inadequate drug supply, prolonged turn-around time of HIV viral load results, delayed integrated Tuberculosis (TB) preventive therapy initiation, stigma and retention challenges. CONCLUSION Multimonth dispensing has the potential to address the health system challenges in Tanzania if guidelines are well informed to stakeholders, and facets of quality of care are improved. Addressing the earmarked barriers such as ensuring medicine, supplies and diagnostics, while addressing retention challenges and stigma.
Collapse
Affiliation(s)
- Neema Machumu
- School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, United Republic of Tanzania
| | - Gasto Frumence
- Department of Public Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
| | - Amani Anaeli
- Department of Research and Publications, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
| |
Collapse
|
3
|
Brian J, Waiswa S, Balinaine J, Lomuria R, Nabutanyi GG, Ongala E, Opus B, Olwedo MA, Iramiot JS, Oboth P, Nekaka R. Sustained Retention, Viral Load Suppression and their Determinants Among Clients on HAART Enrolled Under Differentiated Service Delivery Models in Eastern Uganda. RESEARCH SQUARE 2023:rs.3.rs-3377046. [PMID: 37886502 PMCID: PMC10602122 DOI: 10.21203/rs.3.rs-3377046/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/28/2023]
Abstract
Background Although Uganda rolled out Differentiated Service Delivery(DSD) models in June 2017 to improve retention and viral load suppression rates among clients on Highly Active Antiretroviral Therapy (HAART), these have remained low relative to the Joint United Nations Programme on HIV/AIDS(UNAIDs) targets of achieving 95% population with HIV tested, 95% of tested positive clients for HIV to be on Highly active Antiretroviral therapy and 95% of clients On Antiretroviral therapy be suppressing by 2030(95-95-95 UNAIDS targets). The purpose of this study was to determine sustained retention, viral load suppression and their determinants among clients on HAART enrolled under different Differentiated service delivery models in Katakwi district in Eastern Uganda. Methods A retrospective cohort study of clients enrolled on HAART in the different approaches of DSD who were active by 2017 and followed up to 2020 was done. The primary outcomes included sustained retention, viral load suppression and their determinants among clients HAART in different DSD approaches. Eight health facilities providing HAART services were purposively sampled and 771 clients on HAART were sampled out by simple random selection from a total population of 4742 clients on HAART in Katakwi district. We analysed retention, viral load suppression rates, and their determinants by logistic regression method using STATA. Results A total of 771 participants were sampled of whom 42.7% were male and 57.3% were female, with the mean age being 40 years. Retention rates at 95% CI of participants were 99.35% at 12 months, 94.03 at 24 months, 89.88% at 36 months and 84.57% at 48 months. The viral load suppression rates were 57.3% at 12 months, 70.3% at 24 months, 70.3% at 36 months and 69% at 48 months. Retention was higher in the community based DSD model as compared to the facility-based model. Viral load suppression was higher in the community based DSD models in which Community Drug Distribution Points had the highest achievement (92%) followed by Community Client-Led ART Distribution (79%) compared to the facility based DSD models in which Facility Based Individual Management performance (34.3%) was far below the set standard of 95%, followed by Facility Based Groups (65%) with Fast Track Drug Refill having relatively better performance (80.9%). Being 40-59 years, receiving care from the general hospital, being married, having good current adherence, being on the first line of the current regime and being a female are other predictors of viral load suppression, whereas being 40-59 years of age, having good current adherence, being on the current first-line regime and having no co-morbidities were predictors of good retention. Conclusions generally, facility and community based DSD models have demonstrated improved retention and viral load suppression. However, community-based models have shown to be more effective than facility-based models through mitigation of barriers to effective HIV/AIDS care of clients on HAART. Viral load suppression remained below the UNAIDs target of 95% by 2030, albeit it improved over time.
Collapse
|
4
|
Mekuria AD, Meseret WA, Assefa HK, Sisay AL, Bilchut AH, Derseh BT, Abebe AM, Tesfahun E, Minda A, Equbay M. Time to Virological Failure and Its Predictor Among HIV-Positive Clients with the Differentiated Service Delivery Model of HIV at Debre Berhan Comprehensive Specialized Hospital, Amhara Regional State, Ethiopia, 2021: A Retrospective Cohort Study. AIDS Res Hum Retroviruses 2023; 39:547-557. [PMID: 37183404 DOI: 10.1089/aid.2022.0153] [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: 05/16/2023] Open
Abstract
Diversified antiretroviral therapy (ART) approach is needed in methods that were acceptable to communities and maintain good viral suppression outcomes to reach the UNAIDS targets to end the HIV/AIDS epidemic by 2030. Ethiopia is fully implementing differentiated service delivery (DSD) approaches, appointment spacing, and standard care. This study aimed to determine the time to HIV virological failure and its predictors among patients with a DSD model. An institution-based retrospective cohort study was conducted with data collection dates ranging from May 1, 2021, to May 30, 2021. All adult HIV-positive patients (n = 2,148) between January 2018 and January 2021 were a source population. Data were extracted using a standard checklist by trained data collectors and entered into EpiData, exported to SPSS version 20 for data management, and then exported to R Studio version 1.4 for analysis. Kaplan-Meier survival curves, the log-rank test, and Cox proportional hazard regression models were employed. The incidence of virological failure was 86 per 10,000 person-months. The independent predictors for the hazard of virological failure were being on standard care [adjusted hazard ratios (AHR) = 1.91; 95% confidence interval (CI) 1.07-3.40], primarily educated (AHR = 3.46; 95% CI 1.02-11.72), having no education (AHR = 3.45; 95% CI 1.01-11.85), and ambulatory status at baseline (AHR = 1.81; 95% CI 1.06-3.09). Patients who had a viral load with a detectable range from 50 to 999 at engagement (AHR = 2.65; 95% CI 1.33-5.27) and a 1-month increase in ART for HIV patients (AHR = 1.045; 95% CI 1.01-1.09). The incidence of virological failure was 86 per 10,000 person-months, whereas the incidences were 52 per 10,000 person-months and 71 per 10,000 person-months on appointment spacing model and standard care, respectively, with independent predictors: patient category, educational status, baseline functional status, viral load at engagement, and duration of ART.
Collapse
Affiliation(s)
- Abinet Dagnaw Mekuria
- Department of Public Health, Asrate Woldeyes Health Science Campus, Debre Berhan University, Debre Berhan, Ethiopia
| | - Wondesen Asegidew Meseret
- Department of Public Health, Asrate Woldeyes Health Science Campus, Debre Berhan University, Debre Berhan, Ethiopia
| | - Hilina Ketema Assefa
- Department of Nursing, Asrate Woldeyes Health Science Campus, Debre Berhan University, Debre Berhan, Ethiopia
| | - Assefa Legesse Sisay
- Department of Epidemiology and Bio-Statistics, Public Health Faculty Institute of Health Science, Jimma University, Jimma, Ethiopia
| | - Awraris Hailu Bilchut
- Department of Public Health, Asrate Woldeyes Health Science Campus, Debre Berhan University, Debre Berhan, Ethiopia
| | - Behailu Tariku Derseh
- Department of Public Health, Asrate Woldeyes Health Science Campus, Debre Berhan University, Debre Berhan, Ethiopia
| | - Ayele Mamo Abebe
- Department of Nursing, Asrate Woldeyes Health Science Campus, Debre Berhan University, Debre Berhan, Ethiopia
| | - Esubalew Tesfahun
- Department of Public Health, Asrate Woldeyes Health Science Campus, Debre Berhan University, Debre Berhan, Ethiopia
| | - Abebe Minda
- Department of Public Health, Asrate Woldeyes Health Science Campus, Debre Berhan University, Debre Berhan, Ethiopia
| | - Meseret Equbay
- Department of Public Health, Asrate Woldeyes Health Science Campus, Debre Berhan University, Debre Berhan, Ethiopia
| |
Collapse
|
5
|
Ossomba JPBE, Ngangue P, Ekani ASO, Kamgain ET. De-medicalized and decentralized HIV testing: a strategy to test hard-to-reach men who have sex with men in Cameroon. Front Public Health 2023; 11:1180813. [PMID: 37564422 PMCID: PMC10410143 DOI: 10.3389/fpubh.2023.1180813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 07/11/2023] [Indexed: 08/12/2023] Open
Abstract
Conventional HIV testing performed by a health professional has shown its limitations in targeting marginalized and vulnerable populations. Indeed, men who have sex with men (MSM) due to social discrimination are often uncomfortable using this service at the health facilities level. In this perspective, new differentiated approaches have been thought through de-medicalized and decentralized HIV testing (DDHT). This HIV testing strategy enables overcoming the structural, legal, and social barriers that prevent these populations from quickly accessing HIV services. This article discusses the prerequisites and added value of implementing this strategy for MSM living in a criminalized context and its implication in decentralizing health services toward the community level.
Collapse
|
6
|
Semo BW, Ezeokafor N, Adeyemi S, Kpamor Z, Mugo C. Differentiated service delivery models for antiretroviral treatment refills in Northern Nigeria: Experiences of people living with HIV and health care providers-A qualitative study. PLoS One 2023; 18:e0287862. [PMID: 37428746 DOI: 10.1371/journal.pone.0287862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 06/14/2023] [Indexed: 07/12/2023] Open
Abstract
Differentiated service delivery (DSD) and multi-month dispensing (MMD) of antiretroviral therapy (ART) have improved treatment adherence and viral suppression among people living with HIV (PLHIV), and service delivery efficiency. We assessed the experiences of PLHIV and providers with DSD and MMD in Northern Nigeria. We conducted in-depth interviews (IDI) with 40 PLHIV and 6 focus group discussions (FGD) with 39 health care providers across 5 states, exploring their experiences with 6 DSD models. Qualitative data were analyzed using NVivo®1.6.1. Most PLHIV and providers found the models acceptable and expressed satisfaction with service delivery. The DSD model preference of PLHIV was influenced by convenience, stigma, trust, and cost of care. Both PLHIV and providers indicated improvements in adherence and viral suppression; they also raised concerns about quality of care within community-based models. PLHIV and provider experiences suggest that DSD and MMD have the potential to improve patient retention rates and service delivery efficiency.
Collapse
Affiliation(s)
- Bazghina-Werq Semo
- Global Health Division, Chemonics International, Washington DC, United States of America
| | - Nnenna Ezeokafor
- Maryland Global Initiative Cooperation, University of Maryland, Abuja, Nigeria
- Global Health Division, Chemonics International, Abuja, Nigeria
| | | | - Zipporah Kpamor
- Global Health Division, Chemonics International, Abuja, Nigeria
| | - Cyrus Mugo
- Department of Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| |
Collapse
|
7
|
Harrison N, Lawal I, Aribisala K, Oruka K, Adamu Y, Agaba P, Lee E, Chittenden L, Okeji N. Effect of multi-month antiretroviral dispensing on HIV clinic attendance at 68 Nigerian Army Reference Hospital, Yaba, Nigeria. AFRICAN JOURNAL OF AIDS RESEARCH : AJAR 2023; 22:63-68. [PMID: 37116113 DOI: 10.2989/16085906.2023.2188232] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/30/2023]
Abstract
Background: Multi-month dispensing (MMD) of antiretroviral therapy has demonstrated benefits for HIV patients and health service delivery systems, including reduced frequency of hospital visits and improved retention. We evaluated the effect of 6-monthly dispensing (MMD6) on patient clinic attendance at a single military facility in the one-year pre- and post-policy change.Methods: This was a descriptive, retrospective, cross-sectional study, exploring the relationship between MMD6 and clinic attendance numbers. We reviewed aggregate clinic attendance records for clients on ART and documented monthly trends in clinic attendance numbers, number of clients current on ART, and amount of ART dispensed.Results: In the pre-MMD6 group, 4 150 patients were included, and 4 190 in the post-MMD6 group. Clinic attendance was 30 407 visits (16 111 pre-MMD6 and 14 296 post-MMD6). An overall mean increase of 326.58 ± 861.81 (95% CI = -874.15 ± 220.98) drugs were dispensed per month; t(11) = -1.31, p = 0.22; mean monthly clinic attendance declined from 1342.8 ± 220.10 visits pre-MMD6 to 1191.33 ± 309.10 post-MMD6 with t(11) = 1.601, p = 0.14, but was not statistically significant.Conclusion: Six-monthly dispensing can be an important tool to reduce HIV clinic volumes and improve antiretroviral access. It is particularly important for care continuity in military facilities where service members may be deployed or transferred to other bases along with their dependents.
Collapse
Affiliation(s)
| | - Ismail Lawal
- US Army Medical Research Directorate-Africa, Abuja, Nigeria
| | | | - Kenneth Oruka
- 68 Nigeria Army Reference Hospital, Yaba, Lagos Nigeria
| | - Yakubu Adamu
- US Army Medical Research Directorate-Africa, Abuja, Nigeria
| | - Patricia Agaba
- US Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, USA
| | - Elizabeth Lee
- US Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, USA
| | | | - Nathan Okeji
- Nigerian Ministry of Defence - Health Implementation Program, Abuja, Nigeria
| |
Collapse
|
8
|
Kafwanka P, Nalule FM, Michelo C. Poor adherence to antiretroviral therapy among adult people living with HIV initiated during the COVID-19 epidemic waves – observations at the University Teaching Hospital in Lusaka, Zambia. Front Public Health 2023; 11:1094214. [PMID: 36992897 PMCID: PMC10040650 DOI: 10.3389/fpubh.2023.1094214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 02/22/2023] [Indexed: 03/14/2023] Open
Abstract
BackgroundCoronavirus disease 2019 (COVID-19)-related disruptions in healthcare services and clinical outcomes have been predicted and documented. However, little is known about how antiretroviral therapy (ART) adherence disruptions caused by the COVID-19 pandemic have manifested amidst the ‘Undetectable = Untransmittable' campaign initiative. Using a patient's viral load as a proxy for medication adherence, our study aimed to determine the adherence to ART on first-line medications among adult people living with human immunodeficiency virus (PLWHIV) at the University Teaching Hospital in Lusaka, Zambia during the pandemic.MethodsThis was a hospital-based cross-sectional study. Secondary data of PLWHIV registered to receive ART from the Adult Infectious Disease Centre was extracted from the SmartCare® electronic health record system to constitute a resultant data set that this study used. The data extraction form was used to extract values of dependent (ART adherence measured by viral load detectability) and independent variables and imported them into the statistical analysis tool, STATA version 16.1 MP. Descriptive statistics of individual characteristics, testing for associations using Pearson's chi-square test, and stratified and combined multivariable logistic regression were performed.ResultsOf the 7,281 adult PLWHIV included in this study, 9.0% (95% CI 8.3–9.6%) were virally detectable. Estimates of the odds ratios of detectable viral load remained significantly higher among adult PLWHIV who were initiated on ART after the U=U campaign was launched in Zambia and were on a monthly 2.51 (1.31–9.03) or 6-monthly 4.75 (3.52–6.41) dispensing of a dolutegravir-based regimen and those on 6-monthly dispensing of an efavirenz-based regimen 4.67 (2.16–10.08) compared to their counterparts. Overall estimates showed us the same picture 4.14 (3.22–5.31), having adjusted for all other predictor variables.ConclusionWe found that a high proportion of people with detectable viral load in the study population, irrespective of medication refill interval and type of regimen, was concentrated among adult PLWHIV who started treatment during the COVID-19 epidemic waves, as compared to those who started treatment before the pandemic. This observed disparity suggests the inherent impact of the pandemic on the adherence to ART among adult PLWHIV in Lusaka, Zambia. This further illustrates how exposed program responses are to external shocks, especially in already weakened health systems, and the need to create program response buffers and resilient program-specific strategies to minimize the effect of external disruptions.
Collapse
Affiliation(s)
- Powell Kafwanka
- Department of Epidemiology and Biostatistics, School of Public Health, University of Zambia, Lusaka, Zambia
- Department of Internal Medicine, School of Medicine, University of Zambia, Lusaka, Zambia
- *Correspondence: Powell Kafwanka
| | | | - Charles Michelo
- Department of Epidemiology and Biostatistics, School of Public Health, University of Zambia, Lusaka, Zambia
- Strategic Centre for Health Systems Metrics (SCHEME), Lusaka, Zambia
- Global Health Institute, Nkwazi Research University, Lusaka, Zambia
| |
Collapse
|
9
|
Akpan U, Kakanfo K, Ekele OD, Ukpong K, Toyo O, Nwaokoro P, James E, Pandey S, Olatubosun K, Bateganya M. Predictors of treatment interruption among patients on antiretroviral therapy in Akwa Ibom, Nigeria: outcomes after 12 months. AIDS Care 2023; 35:114-122. [PMID: 35765160 DOI: 10.1080/09540121.2022.2093826] [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: 10/17/2022]
Abstract
Understanding the characteristics of people living with HIV who interrupt antiretroviral therapy (ART) is critical for designing client-centered services to ensure optimal outcomes. We assessed predictors of treatment interruption in 22 HIV clinics in Nigeria. We reviewed records of HIV-positive patients aged ≥15 years who started ART 1 January and 31 March 2019. We determined treatment status over 12 months as either active, or interrupted treatment (defined as interruption in treatment up to 28 days or longer). Potential predictors were assessed using Cox hazard regression models. Overall, 1185 patients were enrolled on ART, 829 (70%) were female, and median age was 32 years. Retention at 1, 3, 6, 9, and 12 months was 85%, 80%, 76%, 72%, and 68%, respectively. Predictors of treatment interruption were post-secondary education (p = 0.04), diagnosis through voluntary counseling and testing (p < 0.001), receiving care at low-volume facilities (p < 0.001), lack of access to a peer counselor (p < 0.001), and residing outside the clinic catchment area (p = 0.03). Treatment interruption was common but can be improved by focusing on lower volume health facilities, providing peer support especially to those with higher education, and client-centered HIV services for those who live further from clinics..
Collapse
Affiliation(s)
- Uduak Akpan
- Achieving Health Nigeria Initiative, Akwa Ibom, Nigeria
| | | | - Oche D Ekele
- Achieving Health Nigeria Initiative, Akwa Ibom, Nigeria
| | - Kufre Ukpong
- Achieving Health Nigeria Initiative, Akwa Ibom, Nigeria
| | - Otoyo Toyo
- Achieving Health Nigeria Initiative, Akwa Ibom, Nigeria
| | | | - Ezekiel James
- United States Agency for International Development, Abuja, Nigeria
| | | | | | | |
Collapse
|
10
|
Miyingo C, Mpayenda T, Nyole R, Ayinembabazi J, Ssepuuya M, Ssebuwufu EM, Puleh SS, Udho S, Kabunga A. HIV Treatment and Care of Adolescents: Perspectives of Adolescents on Community-Based Models in Northern Uganda. HIV AIDS (Auckl) 2023; 15:105-114. [PMID: 36938317 PMCID: PMC10015975 DOI: 10.2147/hiv.s405393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 03/09/2023] [Indexed: 03/12/2023] Open
Abstract
Background Differentiated service delivery models for people living with HIV continue to be scaled up to expand access to HIV services and treatment continuity. However, there is a gap in information on adolescents' perspectives on community-based models. We aimed to explore the perspectives of adolescents living with HIV on community-based models in northern Uganda. Materials and Methods Between February and March 2022, we conducted a descriptive qualitative study at two health centres IV in Northern Uganda. Data was collected using an interview guide. The study had 25 purposively selected adolescents enrolled in community-based models for HIV care and treatment. The interviews were audio-recorded, transcribed verbatim, and translated. We analyzed data using a thematic approach. Results A total of 25 in-depth interviews with HIV-positive adolescents were conducted. More than half (52.0%) of the participants were females, 84.0% were not married, and 44.0% had no formal education. The mean age of the respondents was 15.6 (±1.9) years. The major themes were: community-based models currently accessed by adolescents, benefits, and challenges of the models. Although there are other community-based models (community pharmacies, home ART deliveries) our exploration only discovered two models used by these adolescents to access care, namely, Community Drug Distribution Point (CDDP) and Community Client-Led ART Delivery Groups (CCLADs). The benefits included reduced transportation costs, convenient service access, ART adherence, peer support, a comfortable environment and less stress. However, our results indicate that these models had some challenges, including lack of confidentiality and privacy, perceived stigma, and a lack of face-to-face interaction. Conclusion Our findings show that CDDP and CCLADs are the two CBMs used by adolescents in Lira District to access treatment and care. Adolescents benefited from these models through reduced transport costs, the convenience of accessing HIV care and treatment, and social support. The challenges associated with these models are lack of confidentiality and privacy, perceived stigma, and a lack of face-to-face interaction. The Ministry of Health should work with other implementing partners to strengthen the implementation of these models to improve HIV/AIDS service delivery for adolescents.
Collapse
Affiliation(s)
| | - Teddy Mpayenda
- Department of Midwifery, Lira University, Lira City, Uganda
| | - Ruth Nyole
- Department of Midwifery, Lira University, Lira City, Uganda
| | | | - Mujib Ssepuuya
- Department of Public Health, Lira University, Lira City, Uganda
| | | | | | - Samson Udho
- Department of Midwifery, Lira University, Lira City, Uganda
| | - Amir Kabunga
- Department of Psychiatry, Lira University, Lira City, Uganda
- Correspondence: Amir Kabunga, Department of Psychiatry, Faculty of Medicine, Lira University, P.O BOX 1035, Lira City, Northern Uganda, Email
| |
Collapse
|
11
|
Nalubega S, Osuwat LO, Agyeiwaa PB, Evans C, Matovu JB. The practice of pilot/feasibility studies in informing the conduct of HIV related clinical trials in sub-Saharan Africa: A scoping review. Contemp Clin Trials Commun 2022; 29:100959. [PMID: 35865280 PMCID: PMC9294242 DOI: 10.1016/j.conctc.2022.100959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2022] [Revised: 06/21/2022] [Accepted: 06/27/2022] [Indexed: 11/21/2022] Open
Abstract
Introduction Pilot/feasibility studies represent a fundamental phase of the research process and play a vital role in the preliminary planning of a full size HIV clinical trial. Published HIV clinical trial protocols were reviewed to establish the extent to which the proposed HIV clinical trials are informed by a prior pilot/feasibility study. Methods The JBI methodology for scoping reviews was followed. Six databases were systematically searched to identify articles for inclusion. Results Thirty two (32) published HIV study protocols were included. Articles were in the English language and were published in the past 10 years (2011-2020). The review results showed that the majority of HIV-related clinical trials in sub-Saharan Africa were not informed by pilot/feasibility studies. The results further indicated that the number of HIV clinical trials informed by a pilot/feasibility study have been on the increase in the 8 years' period since 2012, a trend that indicates positive uptake of pilot studies in HIV related studies. A few select countries (South Africa, Uganda, Zimbabwe, Malawi and Kenya) comprised more than 70% of all clinical trials that were informed by a pilot/feasibility study, conducted in sub Saharan Africa. Conclusions Although there is an increasing interest among researchers to integrate pilot/feasibility studies in HIV related research, limited countries in sub-Saharan Africa appear to have embraced this trend. Strategies that can motivate researchers to engage in a culture of incorporating pilot/feasibility studies in HIV related research should be implemented.
Collapse
Affiliation(s)
- Sylivia Nalubega
- School of Health Sciences, Soroti University, Soroti, Uganda
- Corresponding author. Soroti University, School of Health Sciences, Department of Nursing, Uganda.
| | | | - Poku Brenda Agyeiwaa
- School of Sociology and Socio Policy, University of Nottingham, Nottingham, United Kingdom
| | - Catrin Evans
- School of Health Sciences, University of Nottingham, Nottingham, United Kingdom
- University of Nottingham Center for Evidence Based Healthcare, United Kingdom
| | | |
Collapse
|
12
|
Lopes J, Grimwood A, Ngorima-Mabhena N, Tiam A, Tukei BB, Kasu T, Mahachi N, Mothibi E, Tukei V, Chasela C, Lombard C, Fatti G. Out-of-Facility Multimonth Dispensing of Antiretroviral Treatment: A Pooled Analysis Using Individual Patient Data From Cluster-Randomized Trials in Southern Africa. J Acquir Immune Defic Syndr 2021; 88:477-486. [PMID: 34506343 DOI: 10.1097/qai.0000000000002797] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 08/27/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Out-of-facility multi-month dispensing (MMD) is a differentiated service delivery model which provides antiretroviral treatment (ART) at intervals of up to 6 monthly in the community. Limited randomized evidence investigating out-of-facility MMD is available. We evaluated participant outcomes and compared out-of-facility MMD models using data from cluster-randomized trials in Southern Africa. SETTING Eight districts in Zimbabwe and Lesotho. METHODS Individual-level participant data from 2 cluster-randomized trials that included stable adults receiving ART at 60 facilities were pooled. Both trials had 3 arms: ART collected 3-monthly at healthcare facilities (3MF, control); ART provided three-monthly in community ART groups (CAGs) (3MC); and ART provided 6-monthly in either CAGs or on an individual provider-patient basis (6MC). Participant retention, viral suppression and incidence of unscheduled facility visits were compared. RESULTS Ten thousand one hundred thirty-six participants were included, 3817 (37.7%), 2893 (28.5%) and 3426 (33.8%) in arms 3MF, 3MC and 6MC, respectively. After 12 months, retention was non-inferior for 3MC (95.7%) vs. 3MF (95.0%) {adjusted risk difference (aRD) = 0.3 [95% confidence interval (CI): -0.8 to 1.4]}; and 6MC (95.1%) vs. 3MF [aRD = -0.2 (95% CI: -1.4 to 1.0)]. Retention was greater amongst intervention arm participants in CAGs versus 6MC participants not in CAGs, aRD = 1.5% (95% CI: 0.2% to 2.9%). Viral suppression was excellent (≥98%) and unscheduled facility visits were not increased in the intervention arms. CONCLUSIONS Three and 6-monthly out-of-facility MMD was non-inferior versus facility-based care for stable ART patients. Out-of-facility 6-monthly MMD should incorporate small group peer support whenever possible. CLINICALTRIAL REGISTRATION ClinicalTrials.gov NCT03238846 and NCT03438370.
Collapse
Affiliation(s)
- John Lopes
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | | | | | - Appolinaire Tiam
- Elizabeth Glaser Pediatric AIDS Foundation, Washington DC, United States
| | | | | | - Nyika Mahachi
- Zimbabwe College of Public Health Physicians, Harare, Zimbabwe
| | - Eula Mothibi
- Right to Care/EQUIP Health, Centurion, South Africa
| | - Vincent Tukei
- Elizabeth Glaser Pediatric AIDS Foundation, Maseru, Lesotho
| | - Charles Chasela
- Right to Care/EQUIP Health, Centurion, South Africa
- Department of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; and
| | - Carl Lombard
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Biostatistics Unit, South African Medical Research Council, Cape Town, South Africa
| | - Geoffrey Fatti
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Kheth'Impilo AIDS Free Living, Cape Town, South Africa
| |
Collapse
|
13
|
Tomescu S, Crompton T, Adebayo J, Kinge CW, Akpan F, Rennick M, Chasela C, Ondura E, Dauda DS, Pisa PT. Factors associated with an interruption in treatment of people living with HIV in USAID-supported states in Nigeria: a retrospective study from 2000-2020. BMC Public Health 2021; 21:2194. [PMID: 34847909 PMCID: PMC8638522 DOI: 10.1186/s12889-021-12264-9] [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: 05/11/2021] [Accepted: 11/16/2021] [Indexed: 12/04/2022] Open
Abstract
Background Patient interruption of antiretroviral therapy (ART) continues to limit HIV programs’ progress toward epidemic control. Multiple factors have been associated with client interruption in treatment (IIT)— including age, gender, CD4 count, and education level. In this paper, we explore the factors associated with IIT in people living with HIV (PLHIV) in United States Agency for International Development (USAID)-supported facilities under the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) program in Nigeria. Methods We conducted cross-sectional analyses on data obtained from Nigeria’s National Data Repository (NDR), representing a summarized record of 573 630 ART clients that received care at 484 PEPFAR/USAID-supported facilities in 16 states from 2000–2020. IIT was defined as no clinical contact for 28 days or more after the last expected clinical contact. Univariate and multivariate logistic regression models were computed to explore the factors associated with IIT. The variables included in the analysis were sex, age group, zone, facility level, regimen line, multi-month dispensing (MMD), and viral load category. Results Of the 573 630 clients analysed in this study, 32% have been recorded as having interrupted treatment. Of the clients investigated, 66% were female (32% had interrupted treatment), 39% were aged 25–34 at their last ART pick-up date (with 32% of them interrupted treatment), 59% received care at secondary level facilities (37% interrupted treatment) and 38% were last receiving between three- to five-month MMD (with 10% of these interrupted treatment). Those less likely to interrupt ART were males (aOR = 0.91), clients on six-month MMD (aOR = 0.01), adults on 2nd line regimen (aOR = 0.09), and paediatrics on salvage regimen (aOR = 0.02). Clients most likely to interrupt ART were located in the South West Zone (aOR = 1.99), received treatment at a tertiary level (aOR = 12.34) or secondary level facilities (aOR = 4.01), and had no viral load (VL) on record (aOR =10.02). Age group was not significantly associated with IIT. Conclusions Sex, zone, facility level, regimen line, MMD, and VL were significantly associated with IIT. MMD of three months and longer (especially six months) had better retention on ART than those on shorter MMD. Not having a VL on record was associated with a considerable risk of IIT.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Charles Chasela
- Right to Care, Centurion, South Africa.,Division of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | | | - Pedro T Pisa
- Right to Care, Centurion, South Africa.,Department of Human Nutrition and Dietetics, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| |
Collapse
|
14
|
Fatti G, Ngorima-Mabhena N, Tiam A, Tukei BB, Kasu T, Muzenda T, Maile K, Lombard C, Chasela C, Grimwood A. Community-based differentiated service delivery models incorporating multi-month dispensing of antiretroviral treatment for newly stable people living with HIV receiving single annual clinical visits: a pooled analysis of two cluster-randomized trials in southern Africa. J Int AIDS Soc 2021; 24 Suppl 6:e25819. [PMID: 34713614 PMCID: PMC8554219 DOI: 10.1002/jia2.25819] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 08/24/2021] [Indexed: 11/26/2022] Open
Abstract
Introduction Differentiated service delivery (DSD) models for HIV treatment decrease health facility visit frequency and limit healthcare facility‐based exposure to severe acute respiratory syndrome coronavirus 2. However, two important evidence gaps include understanding DSD effectiveness amongst clients commencing DSD within 12 months of antiretroviral treatment (ART) initiation and amongst clients receiving only single annual clinical consultations. To investigate these, we pooled data from two cluster‐randomized trials investigating community‐based DSD in Zimbabwe and Lesotho. Methods Individual‐level participant data of newly stable adults enrolled between 6 and 12 months after ART initiation were pooled. Both trials (conducted between August 2017 and July 2019) had three arms: Standard‐of‐care three‐monthly ART provision at healthcare facilities (SoC, control); ART provided three‐monthly in community ART groups (CAGs) (3MC) and ART provided six‐monthly in either CAGs or at community‐distribution points (6MC). Clinical visits were three‐monthly in SoC and annually in intervention arms. The primary outcome was retention in care and secondary outcomes were viral suppression (VS) and number of unscheduled facility visits 12 months after enrolment. Individual‐level regression analyses were conducted by intention‐to‐treat specifying for clustering and adjusted for country. Results and Discussion A total of 599 participants were included; 212 (35.4%), 128 (21.4%) and 259 (43.2%) in SoC, 3MC and 6MC, respectively. Few participants aged <25 years were included (n = 32). After 12 months, 198 (93.4%), 123 (96.1%) and 248 (95.8%) were retained in SoC, 3MC and 6MC, respectively. Retention in 3MC was superior versus SoC, adjusted risk difference (aRD) = 4.6% (95% CI: 0.7%−8.5%). Retention in 6MC was non‐inferior versus SoC, aRD = 1.7% (95% CI: −2.5%−5.9%) (prespecified non‐inferiority aRD margin −3.25%). VS was similar between arms, 99.3, 98.6 and 98.1% in SoC, 3MC and 6MC, respectively. Adjusted risk ratio's for VS were 0.98 (95% CI: 0.92−1.03) for 3MC versus SoC, and 0.98 (CI: 0.95−1.00) for 6MC versus SoC. Unscheduled clinic visits were not increased in intervention arms: incidence rate ratio = 0.53 (CI: 0.16−1.80) for 3MC versus SoC; and 0.82 (CI: 0.25−2.79) for 6MC versus SoC. Conclusions Community‐based DSD incorporating three‐ and six‐monthly ART refills and single annual clinical visits were at least non‐inferior to standard facility‐based care amongst newly stable ART clients aged ≥25 years. ClinicalTrials.gov: NCT03238846 & NCT03438370
Collapse
Affiliation(s)
- Geoffrey Fatti
- Kheth'Impilo AIDS Free Living, Cape Town, South Africa.,Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | | | | | | | | | - Trish Muzenda
- Kheth'Impilo AIDS Free Living, Cape Town, South Africa.,Division of Public Health Medicine, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Carl Lombard
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.,Biostatistics Unit, South African Medical Research Council, Cape Town, South Africa
| | - Charles Chasela
- Right to Care/EQUIP Health, Centurion, South Africa.,Department of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | |
Collapse
|
15
|
Kintu TM, Ssewanyana AM, Kyagambiddwa T, Nampijja PM, Apio PK, Kitaka J, Kabakyenga JK. Exploring drivers and barriers to the utilization of community client-led ART delivery model in South-Western Uganda: patients' and health workers' experiences. BMC Health Serv Res 2021; 21:1129. [PMID: 34670564 PMCID: PMC8527820 DOI: 10.1186/s12913-021-07105-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 09/28/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND In an effort to accommodate the growing number of HIV clients, improve retention in care and reduce health care burden, the differentiated service delivery (DSD) models were introduced in 2014. One such model, Community Client-Led ART Delivery (CCLAD) was rolled out in Uganda in 2017. The extent of utilization of this model has not been fully studied. The aim of the study was to explore the patients' and health workers' experiences on the utilization of CCLAD model at Bwizibwera Health Centre IV, south western Uganda. METHODS This was a descriptive study employing qualitative methods. The study had 68 purposively selected participants who participated in 10 focus group discussions with HIV clients enrolled in CCLAD; 10 in-depth interviews with HIV clients not enrolled in CCLAD and 6 in-depth interviews with the health workers. Key informant interviews were held with the 2 focal persons for DSD. The discussions and interviews were audio recorded, transcribed verbatim and then translated. Both deductive and inductive approaches were employed to analyse the data using in NVivo software. RESULTS Patients' and health workers' experiences in this study were categorized as drivers and barriers to the utilization of the CCLAD model. The main drivers for utilization of this model at different levels were: individual (reduced costs, living positively with HIV, improved patient self-management), community (peer support and contextual factors) and health system (reduced patient congestion at the health centre, caring health workers as well as CCLAD sensitization by health workers). However, significant barriers to the utilization of this community-based model were: individual (personal values and preferences, lack of commitment of CCLAD group members), community (stigma, gender bias) and health system (frequent drug stockouts, certain implementation challenges, fluctuating implementing partner priorities, shortage of trained health workers and insufficient health education by health workers). CONCLUSION Based on our findings the CCLAD model is meeting the objectives set out by Differentiated Service Delivery for HIV care and treatment. Notwithstanding the benefits, challenges remain which call on the Ministry of Health and other implementing partners to address these hindrances to facilitate the scalability, sustainability and the realisation of the full-range of benefits that the model presents.
Collapse
Affiliation(s)
- Timothy Mwanje Kintu
- Faculty of Medicine, Mbarara University of Science and Technology, P.O. Box 1410, Mbarara, Uganda
| | - Anna Maria Ssewanyana
- Faculty of Medicine, Mbarara University of Science and Technology, P.O. Box 1410, Mbarara, Uganda
| | - Tonny Kyagambiddwa
- Faculty of Medicine, Mbarara University of Science and Technology, P.O. Box 1410, Mbarara, Uganda
| | - Pretty Mariam Nampijja
- Faculty of Medicine, Mbarara University of Science and Technology, P.O. Box 1410, Mbarara, Uganda
| | - Patience Kevin Apio
- Faculty of Medicine, Mbarara University of Science and Technology, P.O. Box 1410, Mbarara, Uganda
| | - Jessica Kitaka
- Faculty of Medicine, Mbarara University of Science and Technology, P.O. Box 1410, Mbarara, Uganda
| | - Jerome Kahuma Kabakyenga
- Faculty of Medicine, Mbarara University of Science and Technology, P.O. Box 1410, Mbarara, Uganda.
| |
Collapse
|
16
|
Tuot S, Teo AKJ, Prem K, Chhoun P, Pall C, Ung M, Ly PS, Jimba M, Yi S. Community-based model for the delivery of antiretroviral therapy in Cambodia: a quasi-experimental study protocol. BMC Infect Dis 2021; 21:763. [PMID: 34362310 PMCID: PMC8344198 DOI: 10.1186/s12879-021-06414-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 07/01/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Multi-month dispensing (MMD) is the mainstay mechanism for clinically stable people living with HIV in Cambodia to refill antiretroviral therapy (ART) every 3-6 months. However, less frequent ART dispensing through the community-based ART delivery (CAD) model could further reduce the clients' and health facilities' burden. While community-based services have been recognized as an integral component of HIV response in Cambodia, their role and effectiveness in ART delivery have yet to be systematically assessed. This study aims to evaluate the CAD model's effectiveness on the continuum of care and treatment outcomes for stable people living with HIV in Cambodia. METHODS We will conduct this quasi-experimental study in 20 ART clinics across the capital city and nine provinces between May 2021 and April 2023. Study sites were purposively selected based on the availability of implementing partners, the number of people living with HIV each clinic serves, and the accessibility of the clinics. In the intervention arm, approximately 2000 stable people living with HIV will receive ART and services from the CAD model. Another 2000 stable people living with HIV in the control arm will receive MMD-a standard care model for stable people living with HIV. The primary outcomes will be retention in care, viral load suppression, and adherence to ART. The secondary endpoints will include health providers' work burden, the model's cost-effectiveness, quality of life, mental health, social support, stigma, and discrimination. We will compare the outcome indicators within each arm at baseline, midline, and endline using descriptive and inferential statistics. We will evaluate the differences between the intervention and control arms using the difference-in-differences method. We will perform economic evaluations to determine if the intervention is cost-effective. DISCUSSION This study will build the evidence base for future implementation and scale-up of CAD model in Cambodia and other similar settings. Furthermore, it will strengthen engagements with community stakeholders and further improve community mobilization, a vital pillar of the Cambodian HIV response. TRIAL REGISTRATION ClinicalTrials.gov, NCT04766710 . Registered 23 February 2021, Version 1.
Collapse
Affiliation(s)
- Sovannary Tuot
- KHANA Center for Population Health Research, Phnom Penh, Cambodia
- Department of Community and Global Health, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
- Faculty of Social Sciences and Humanity, Royal University of Phnom Penh, Phnom Penh, Cambodia
| | - Alvin Kuo Jing Teo
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, 12 Science Drive 2, #10-01, Singapore, 117549, Singapore
| | - Kiesha Prem
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, 12 Science Drive 2, #10-01, Singapore, 117549, Singapore
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Pheak Chhoun
- KHANA Center for Population Health Research, Phnom Penh, Cambodia
| | - Chamroen Pall
- KHANA Center for Population Health Research, Phnom Penh, Cambodia
| | - Mengieng Ung
- KHANA Center for Population Health Research, Phnom Penh, Cambodia
- Lee Kuan Yew Centre for Innovative Cities, Singapore University of Technology and Design, Singapore, Singapore
| | - Penh Sun Ly
- National Center for HIV/AIDS, Dermatology and STD, Phnom Penh, Cambodia
| | - Masamine Jimba
- Department of Community and Global Health, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Siyan Yi
- KHANA Center for Population Health Research, Phnom Penh, Cambodia.
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, 12 Science Drive 2, #10-01, Singapore, 117549, Singapore.
- Center for Global Health Research, Touro University California, Vallejo, CA, USA.
| |
Collapse
|
17
|
Zimmer AJ, Heitkamp P, Malar J, Dantas C, O'Brien K, Pandita A, Waite RC. Facility-based directly observed therapy (DOT) for tuberculosis during COVID-19: A community perspective. J Clin Tuberc Other Mycobact Dis 2021; 24:100248. [PMID: 34189276 PMCID: PMC8225462 DOI: 10.1016/j.jctube.2021.100248] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Facility-based directly observed therapy (DOT) has been the standard for treating people with TB since the early 1990s. As the commitment to promote a people-centred model of care for TB grows, the use of facility-based DOT has been questioned as issues of freedom, privacy, and human rights have been raised. The disruptions caused by the COVID-19 pandemic and ensuing lockdown measures have fast-tracked the need to find alternative methods to provide treatment to people with TB. In this study, we present quantitative and qualitative findings from a global community-based survey on the challenges of administering facility-based DOT during a pandemic as well as potential alternatives. Our results found that decreased access to transportation, the fear of COVID-19, stigmatization due to overlapping symptoms, and punitive measures against quarantine violations have made it difficult for persons with TB to receive treatment at facilities, particularly in low-resource settings. Potential replacements included greater focus on community-based DOT, home delivery of treatment, multi-month dispensing, and video DOT strategies. Our study highlights the need for TB programs to re-evaluate their approach to providing treatment to people with TB, and that these changes must be made in consultation with people affected by TB and TB survivors to provide a true people-centred model of care.
Collapse
Affiliation(s)
- Alexandra J. Zimmer
- Department of Epidemiology, Biostatistics & Occupational Health, McGill University, Montreal, Canada
- McGill International TB Centre, Montreal, Canada
| | - Petra Heitkamp
- McGill International TB Centre, Montreal, Canada
- TB PPM Learning Network, Research Institute of the McGill University Health Centre, Canada
| | | | | | - Kate O'Brien
- We are TB/National TB Controllers Association, Smryna, USA
| | - Aakriti Pandita
- Division of Infectious Diseases, University of Colorado School of Medicine, Denver, USA
| | | |
Collapse
|
18
|
Dakum P, Ajav-Nyior J, Attah TA, Kayode GA, Gomwalk A, Omuh H, Ibrahim H, Omozuafoh M, Alash’le A, Mensah C, Oluokun Y, Akolawole F. Effect of community antiretroviral therapy on treatment outcomes among stable antiretroviral therapy patients in Nigeria: A quasi experimental study. PLoS One 2021; 16:e0250345. [PMID: 33901199 PMCID: PMC8075245 DOI: 10.1371/journal.pone.0250345] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 04/05/2021] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES This study evaluates the effect of Community Anti-retroviral Groups on Immunologic, Virologic and clinical outcomes of stable Antiretroviral Therapy patients in Nigeria. METHOD A cohort of 251 eligible adults (≥18 years) on first-line ART for at least 6 months with CD4 counts >200 cells/mm3 and viral load <1000 c/ml were devolved from 10 healthcare facilities to 51 community antiretroviral therapy groups. Baseline immunologic, virologic and clinical parameters were collected and community antiretroviral therapy group patients were followed up for a year after which Human Immunodeficiency Virus treatment outcomes at the baseline and a year after follow-up were compared using paired sample t-test. All the analyses were performed in STATA version 14. RESULT Out of the 251 stable antiretroviral therapy adults enrolled, 186 (75.3%) were female, 52 (22.7%) had attained post-secondary education and the mean age of participants was 38 years (SD: 9.5). Also, 66 (27.9%) were employed while 125 (52.7%) were self-employed and 46(19.41%) unemployed. 246 (98.0%) of the participants were retained in care. While there was no statistically significant change in the CD4 counts (456cells/mm3 vs 481cells/mm3 P-0.489) and Log10 viral load (3.54c/ml vs 3.69c/ml P-0.359) after one year of devolvement into the community, we observed a significant increase in body weight (60.8 vs 65, P-0.01). CONCLUSION This study demonstrates that community antiretroviral therapy has a potential of maintaining optimum treatment outcomes while improving adherence and retention, and reducing the burden of HIV treatment on the health facility. This study provides baseline information for further research and vital information for HIV program implementers planning to decentralize the management of stable antiretroviral therapy clients.
Collapse
Affiliation(s)
- Patrick Dakum
- Institute of Human Virology, Maina Court, Central Business District, Abuja, Nigeria
- Institute of Human Virology University of Maryland School of Medicine, Baltimore, Maryland, United States of America
| | - Juliet Ajav-Nyior
- Institute of Human Virology, Maina Court, Central Business District, Abuja, Nigeria
| | - Timothy A. Attah
- Institute of Human Virology, Maina Court, Central Business District, Abuja, Nigeria
| | - Gbenga A. Kayode
- Institute of Human Virology, Maina Court, Central Business District, Abuja, Nigeria
- International Research Centre of Excellence, Institute of Human Virology, Maina Court, Central Business District, Abuja, Nigeria
| | - Asabe Gomwalk
- Institute of Human Virology, Maina Court, Central Business District, Abuja, Nigeria
| | - Helen Omuh
- Institute of Human Virology, Maina Court, Central Business District, Abuja, Nigeria
| | - Halima Ibrahim
- Institute of Human Virology, Maina Court, Central Business District, Abuja, Nigeria
| | - Mercy Omozuafoh
- Institute of Human Virology, Maina Court, Central Business District, Abuja, Nigeria
| | - Abimiku Alash’le
- Institute of Human Virology University of Maryland School of Medicine, Baltimore, Maryland, United States of America
- International Research Centre of Excellence, Institute of Human Virology, Maina Court, Central Business District, Abuja, Nigeria
| | - Charles Mensah
- Institute of Human Virology, Maina Court, Central Business District, Abuja, Nigeria
| | - Young Oluokun
- Institute of Human Virology, Maina Court, Central Business District, Abuja, Nigeria
| | - Franca Akolawole
- Institute of Human Virology, Maina Court, Central Business District, Abuja, Nigeria
| |
Collapse
|
19
|
Nichols BE, Cele R, Lekodeba N, Tukei B, Ngorima-Mabhena N, Tiam A, Maotoe T, Sejana MV, Faturiyele IO, Chasela C, Rosen S, Fatti G. Economic evaluation of differentiated service delivery models for HIV treatment in Lesotho: costs to providers and patients. J Int AIDS Soc 2021; 24:e25692. [PMID: 33838012 PMCID: PMC8035675 DOI: 10.1002/jia2.25692] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 01/25/2021] [Accepted: 02/23/2021] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION Lesotho, the country with the second-highest HIV/AIDS prevalence (23.6%) in the world, has made considerable progress towards achieving the "95-95-95" UNAIDS targets, but recent success in improving treatment access to all known HIV positive individuals has severely strained existing healthcare infrastructure, financial and human resources. Lesotho also faces the challenge of a largely rural population who incur a significant time and financial burden to visit healthcare facilities. Using data from a cluster-randomized non-inferiority trial conducted between August 2017 and July 2019, we evaluated costs to providers and costs to patients of community-based differentiated models of multi-month delivery of antiretroviral therapy (ART) in Lesotho. METHODS The trial of multi-month dispensing compared 12-month retention in care among three arms: conventional care, which required quarterly facility visits and ART dispensation (3MF); three-month community adherence groups (CAGs) (3MC) and six-month community ART distribution (6MCD). We first estimated the average total annual cost of providing HIV care and treatment followed by the total cost per patient retained 12 months after entry for each arm, using resource utilization data from the trial and local unit costs. We then estimated the average annual cost to patients in each arm with self-reported questionnaire data. RESULTS The average total annual cost of providing HIV care and treatment per patient was the highest in the 3MF arm ($122.28, standard deviation [SD] $23.91), followed by 3MC ($114.20, SD $23.03) and the 6MCD arm ($112.58, SD $21.44). Per patient retained in care, the average provider cost was $125.99 (SD $24.64) in the 3MF arm and 6% to 8% less for the other two arms ($118.38, SD $23.87 and $118.83, SD $22.63 for the 3MC and 6MCD respectively). There was a large reduction in patient costs for both differentiated service delivery arms: from $44.42 (SD $12.06) annually in the 3MF arm to $16.34 (SD $5.11) annually in the 3MC (63% reduction) and $18.77 (SD $8.31) annually in 6MCD arm (58% reduction). CONCLUSIONS Community-based, multi-month models of ART in Lesotho are likely to produce small cost savings to treatment providers and large savings to patients in Lesotho. Patient cost savings may support long-term adherence and retention in care.
Collapse
Affiliation(s)
- Brooke E Nichols
- Department of Global Health, School of Public Health, Boston University, Boston, MA, USA.,Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Refiloe Cele
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Nkgomeleng Lekodeba
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Betty Tukei
- Right to Care, Centurion, South Africa.,EQUIP Lesotho, Maseru, Lesotho
| | | | | | | | | | - Iyiola O Faturiyele
- Department of Epidemiology & Biostatistics, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Charles Chasela
- Right to Care, Centurion, South Africa.,USAID, Washington DC, USA
| | - Sydney Rosen
- Department of Global Health, School of Public Health, Boston University, Boston, MA, USA.,Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Geoffrey Fatti
- Kheth'Impilo AIDS Free Living, Cape Town, South Africa.,Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| |
Collapse
|
20
|
Twelve-Month Outcomes of Community-Based Differentiated Models of Multimonth Dispensing of ART Among Stable HIV-Infected Adults in Lesotho: A Cluster-Randomized Noninferiority Trial. J Acquir Immune Defic Syndr 2021; 85:280-291. [PMID: 32665460 DOI: 10.1097/qai.0000000000002439] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Lesotho adopted the test-and-treat approach for HIV treatment in June 2016, which increased antiretroviral treatment (ART) clinic volume. We evaluated community-based vs. facility-based differentiated models of multimonth dispensing of ART among stable HIV-infected adults in Lesotho. METHODS Thirty facilities were randomized to 3 arms, facility 3-monthly ART (3MF) (control), community ART groups (3MC), and 6-monthly community distribution points (6MCD). We estimated risk differences (RDs) between arms using population-averaged generalized estimating equations, controlling for baseline imbalances and specifying for clustering. The primary outcome was retention in ART care by intention-to-treat and virologic suppression as a secondary outcome (ClinicalTrials.gov: NCT03438370). RESULTS A total of 5,336 participants were enrolled, with 1898, 1558, and 1880 in 3MF, 3MC, and 6MCD, respectively. Retention in ART care was not different across arms and achieved the prespecified noninferiority limit (-3.25%) between 3MC vs. 3MF (control); 6MCD vs. 3MF; and 6MCD vs. 3MC, adjusted RD = -0.1% [95% confidence interval (CI): -1.6% to 1.5%], adjusted RD = -1.3% (95% CI: -3.0% to 0.5%), and adjusted RD = -1.2% (95% CI: -2.9% to 0.5%), respectively. After 12 months, 98.6% (n = 1503), 98.1% (n = 1126), and 98.3% (n = 1285) were virally load (VL) suppressed in 3MF, 3MC, and 6MCD, respectively. There were no differences in VL between 3MC vs. control and 6MCD vs. control, risk ratio (RR) = 1.00 (95% CI: 0.98 to 1.01) and RR = 1.00 (95% CI: 0.98 to 1.01), respectively. CONCLUSIONS There were no differences in retention and VL suppression for stable HIV-infected participants receiving multimonth dispensing of ART within community-based differentiated models when compared with the facility-based standard-of-care model.
Collapse
|
21
|
Jopling R, Nyamayaro P, Andersen LS, Kagee A, Haberer JE, Abas MA. A Cascade of Interventions to Promote Adherence to Antiretroviral Therapy in African Countries. Curr HIV/AIDS Rep 2021; 17:529-546. [PMID: 32776179 PMCID: PMC7497365 DOI: 10.1007/s11904-020-00511-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Purpose of Review We reviewed interventions to improve uptake and adherence to antiretroviral therapy (ART) in African countries in the Treat All era. Recent Findings ART initiation can be improved by facilitated rapid receipt of first prescription, including community-based linkage and point-of-care strategies, integration of HIV care into antenatal care and peer support for adolescents. For people living with HIV (PLHIV) on ART, scheduled SMS reminders, ongoing intensive counselling for those with viral non-suppression and economic incentives for the most deprived show promise. Adherence clubs should be promoted, being no less effective than facility-based care for stable patients. Tracing those lost to follow-up should be targeted to those who can be seen face-to-face by a peer worker. Summary Investment is needed to promote linkage to initiating ART and for differentiated approaches to counselling for youth and for those with identified suboptimal adherence. More evidence from within Africa is needed on cost-effective strategies to identify and support PLHIV at an increased risk of non-adherence across the treatment cascade. Electronic supplementary material The online version of this article (10.1007/s11904-020-00511-4) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Rebecca Jopling
- Health Service & Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Primrose Nyamayaro
- Department of Psychiatry, University of Zimbabwe College of Health Sciences, Mazowe Street, Avondale, Harare, Zimbabwe
| | - Lena S Andersen
- HIV Mental Health Research Unit, Division of Neuropsychiatry, Department of Psychiatry and Mental Health, University of Cape Town, Groote Schuur Hospital Anzio Road, Observatory, Cape Town, South Africa
| | - Ashraf Kagee
- Department of Psychology, Stellenbosch University, Stellenbosch, 7602, South Africa
| | - Jessica E Haberer
- Center for Global Health, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Melanie Amna Abas
- Health Service & Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK.
| |
Collapse
|
22
|
Plymoth M, Sanders EJ, Van Der Elst EM, Medstrand P, Tesfaye F, Winqvist N, Balcha T, Björkman P. Socio-economic condition and lack of virological suppression among adults and adolescents receiving antiretroviral therapy in Ethiopia. PLoS One 2020; 15:e0244066. [PMID: 33320900 PMCID: PMC7737988 DOI: 10.1371/journal.pone.0244066] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 12/02/2020] [Indexed: 12/25/2022] Open
Abstract
Introduction The potential impact of socio-economic condition on virological suppression during antiretroviral treatment (ART) in sub-Saharan Africa is largely unknown. In this case-control study, we compared socio-economic factors among Ethiopian ART recipients with lack of virological suppression to those with undetectable viral load (VL). Methods Cases (VL>1000 copies/ml) and controls (VL<150 copies/ml) aged ≥15years, with ART for >6 months and with available VL results within the last 3 months, were identified from registries at public ART clinics in Central Ethiopia. Questionnaire-based interviews on socio-economic characteristics, health condition and transmission risk behavior were conducted. Univariate variables associated with VL>1000 copies/ml (p<0.25) were added to a multivariable logistic regression model. Results Among 307 participants (155 cases, 152 controls), 61.2% were female, and the median age was 38 years (IQR 32–46). Median HIV-RNA load among cases was 6,904 copies/ml (IQR 2,843–26,789). Compared to controls, cases were younger (median 36 vs. 39 years; p = 0.004), more likely to be male (46.5% vs. 30.9%; p = 0.005) and had lower pre-ART CD4 cell counts (170 vs. 220 cells/μl; p = 0.009). In multivariable analysis of urban residents (94.8%), VL>1000 copies/ml was associated with lower relative wealth (adjusted odds ratio [aOR] 2.98; 95% CI 1.49–5.94; p = 0.016), geographic work mobility (aOR 6.27, 95% CI 1.82–21.6; p = 0.016), younger age (aOR 0.94 [year], 95% CI 0.91–0.98; p = 0.011), longer duration of ART (aOR 1.19 [year], 95% CI 1.07–1.33; p = 0.020), and suboptimal (aOR 3.83, 95% CI 1.33–10.2; p = 0.048) or poor self-perceived wellbeing (aOR 9.75, 95% CI 2.85–33.4; p = 0.012), after correction for multiple comparisons. High-risk sexual behavior and substance use was not associated with lack of virological suppression. Conclusion Geographic work mobility and lower relative wealth were associated with lack of virological suppression among Ethiopian ART recipients in this predominantly urban population. These characteristics indicate increased risk of treatment failure and the need for targeted interventions for persons with these risk factors.
Collapse
Affiliation(s)
- Martin Plymoth
- Clinical Infection Medicine, Department of Translational Medicine, Lund University, Malmö, Sweden
- * E-mail: ,
| | - Eduard J. Sanders
- Centre for Geographic Medicine Research, Kenya Medical Research Institute (KEMRI), Kilifi, Kenya
- Nuffield Department of Clinical Medicine, University of Oxford, Headington, United Kingdom
| | - Elise M. Van Der Elst
- Centre for Geographic Medicine Research, Kenya Medical Research Institute (KEMRI), Kilifi, Kenya
| | - Patrik Medstrand
- Clinical Virology, Department of Translational Medicine, Lund University, Malmö, Sweden
| | - Fregenet Tesfaye
- Clinical Infection Medicine, Department of Translational Medicine, Lund University, Malmö, Sweden
| | - Niclas Winqvist
- Clinical Infection Medicine, Department of Translational Medicine, Lund University, Malmö, Sweden
| | - Taye Balcha
- Clinical Infection Medicine, Department of Translational Medicine, Lund University, Malmö, Sweden
| | - Per Björkman
- Clinical Infection Medicine, Department of Translational Medicine, Lund University, Malmö, Sweden
- Department of Infectious Diseases, Skåne University Hospital, Malmö, Sweden
| |
Collapse
|
23
|
Traub AM, Ifafore-Calfee T, Frymus D, Phelps BR. Multimonth dispensing of antiretroviral therapy for HIV. Lancet HIV 2020; 7:e457-e458. [PMID: 32621873 DOI: 10.1016/s2352-3018(20)30169-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 04/13/2020] [Accepted: 05/26/2020] [Indexed: 06/11/2023]
Affiliation(s)
- Ariana Moriah Traub
- The Sustaining Technical and Analytic Resources program funded by the US Agency for International Development (USAID) and implemented by Public Health Institute, Washington, DC 20547, USA.
| | | | - Diana Frymus
- USAID, Bureau for Global Health, and Office of HIV/AIDS, Washington, DC, USA
| | | |
Collapse
|
24
|
Traub AM, Ifafore-Calfee T, Phelps BR. Multimonth Dispensing of Antiretroviral Therapy Protects the Most Vulnerable From 2 Pandemics at Once. GLOBAL HEALTH: SCIENCE AND PRACTICE 2020; 8:176-177. [PMID: 32606089 PMCID: PMC7326512 DOI: 10.9745/ghsp-d-20-00160] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 05/06/2020] [Indexed: 11/15/2022]
Abstract
We encourage governments in countries that have a high prevalence of people living with HIV to implement multimonth dispensing of antiretroviral therapy to safeguard both patients with HIV and health care workers from coronavirus disease COVID-19.
Collapse
Affiliation(s)
- Ariana Moriah Traub
- Sustaining Technical and Analytic Resources, United States Agency for International Development (USAID), Washington, DC, USA.
| | | | | |
Collapse
|
25
|
Hubbard J, Phiri K, Moucheraud C, McBride K, Bardon A, Balakasi K, Lungu E, Dovel K, Kakwesa G, Hoffman RM. A Qualitative Assessment of Provider and Client Experiences With 3- and 6-Month Dispensing Intervals of Antiretroviral Therapy in Malawi. GLOBAL HEALTH: SCIENCE AND PRACTICE 2020; 8:18-27. [PMID: 32015007 PMCID: PMC7108939 DOI: 10.9745/ghsp-d-19-00286] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 12/10/2019] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Multimonth dispensing (MMD) of antiretroviral therapy (ART) is a differentiated model of care that can help overcome health system challenges and reduce the burden of HIV care on clients. Although 3-month dispensing has been the standard of care, interest has increased in extending refill intervals to 6 months. We explored client and provider experiences with MMD in Malawi as part of a cluster randomized trial evaluating 3- versus 6-month ART dispensing. METHODS Semi-structured in-depth interviews were conducted with 17 ART providers and 62 stable, adult clients with HIV on ART. Clients and providers were evenly divided by arm and were eligible for an interview if they had been participating in the study for 1 year (clients) or 6 months (providers). Questions focused on perceived challenges and benefits of the 3- or 6-month amount of ART dispensing. Interviews were transcribed, and data were coded and analyzed using constant comparison. RESULTS Both clients and providers reported that the larger medication supply had benefits. Clients reported decreased costs due to less frequent travel to the clinic and increased time for income-generating activities. Clients in the 6-month dispensing arm reported a greater sense of personal freedom and normalcy. Providers felt that the 6-month dispensing interval reduced their workload. They also expressed concerned about clients' challenges with ART storage at home, but clients reported no storage problems. Although providers mentioned the potential risk of clients sharing the larger medication supply with family or friends, clients emphasized the value of ART and reported only rare, short-term sharing, mostly with their spouses. Providers mentioned clients' lack of motivation to seek care for illnesses that might occur between refill appointments. CONCLUSIONS The 6-month ART dispensing arm was particularly beneficial to clients for decreased costs, increased time for income generation, and a greater sense of normalcy. Providers' concerns about storage, sharing, and return visits to the facility did not emerge in client interviews. Further data are needed on the feasibility of implementing a large-scale program with 6-month dispensing.
Collapse
Affiliation(s)
- Julie Hubbard
- University of California Los Angeles, David Geffen School of Medicine, Division of Infectious Diseases, Los Angeles, CA, USA. .,Partners in Hope Medical Center, Lilongwe, Malawi
| | - Khumbo Phiri
- Partners in Hope Medical Center, Lilongwe, Malawi
| | - Corrina Moucheraud
- University of California Los Angeles, Fielding School of Public Health, Department of Health Policy and Management, Los Angeles, CA, USA
| | - Kaitlyn McBride
- University of California Los Angeles, Fielding School of Public Health, Department of Health Policy and Management, Los Angeles, CA, USA
| | - Ashley Bardon
- University of Washington, School of Public Health, Department of Epidemiology, Seattle, WA, USA
| | | | - Eric Lungu
- Partners in Hope Medical Center, Lilongwe, Malawi
| | - Kathryn Dovel
- University of California Los Angeles, David Geffen School of Medicine, Division of Infectious Diseases, Los Angeles, CA, USA
| | - Gift Kakwesa
- Partners in Hope Medical Center, Lilongwe, Malawi
| | - Risa M Hoffman
- University of California Los Angeles, David Geffen School of Medicine, Division of Infectious Diseases, Los Angeles, CA, USA
| |
Collapse
|