Factors influencing adherence to antiretroviral treatment among adults accessing care from private health facilities in Malawi

Knowledge and perceptions about Dolutegravir and Dolutegravir counselling: a qualitative study among women living with HIV

INTRODUCTION

In 2018, the Malawi Ministry of Health adopted the recommendation to switch first-line antiretroviral therapy (ART) from an efavirenz (EFV)-based to a dolutegravir (DTG)-based regimen. Little is known about patients' experience during this transition. We conducted a qualitative study to explore DTG-related counselling challenges among providers of HIV care and factors influencing regimen switching or non-switching among women living with HIV in Lilongwe, Malawi.

METHODS

Between February-July 2020, we recruited participants who took part in DTG counselling on reasons to switch, side effects, and benefits from two government health facilities providing HIV care: Area 18 health centre and Bwaila district hospital in Lilongwe, Malawi. We purposively sampled and interviewed 8 women living with HIV who remained on an EFV-based regimen after counselling, 10 women who switched to a DTG-based regimen, and 10 HIV care providers who provided counselling about ART switching. In-depth interviews were used to explore patient's perceptions of DTG, factors affecting the decision to switch, and both patient and provider experience with counselling. Interview data was coded for themes using inductive and deductive codes. Interviews were conducted until thematic saturation was achieved. Data matrices were used for analysis and thematic extraction.

RESULTS

Most women in both groups were well versed on DTG's potential side effects and felt well counselled on the benefits of switching, such as quicker viral load suppression. Many women associated DTG with birth defects and expressed concern. However, the primary reason for not switching was concern with how the new medication would be tolerated, especially when they were satisfied with their current regimen. Almost all providers expressed difficulty providing DTG counselling. Primary reasons included feeling inadequately trained and/or not having resources to use during counselling, such as diagrams or brochures.

CONCLUSION

DTG counselling was well accepted by women; however, some felt that their concerns were not fully addressed. Providers reflected this sentiment in that they did not feel adequately trained or well-equipped to provide adequate counselling. Training on counselling for new ART regimens should be intensified and utilize patient-centered educational materials to address the concerns raised by both patients and health care providers.

Historical visit attendance as predictor of treatment interruption in South African HIV patients: Extension of a validated machine learning model

Retention of antiretroviral (ART) patients is a priority for achieving HIV epidemic control in South Africa. While machine-learning methods are being increasingly utilised to identify high risk populations for suboptimal HIV service utilisation, they are limited in terms of explaining relationships between predictors. To further understand these relationships, we implemented machine learning methods optimised for predictive power and traditional statistical methods. We used routinely collected electronic medical record (EMR) data to evaluate longitudinal predictors of lost-to-follow up (LTFU) and temporal interruptions in treatment (IIT) in the first two years of treatment for ART patients in the Gauteng and North West provinces of South Africa. Of the 191,162 ART patients and 1,833,248 visits analysed, 49% experienced at least one IIT and 85% of those returned for a subsequent clinical visit. Patients iteratively transition in and out of treatment indicating that ART retention in South Africa is likely underestimated. Historical visit attendance is shown to be predictive of IIT using machine learning, log binomial regression and survival analyses. Using a previously developed categorical boosting (CatBoost) algorithm, we demonstrate that historical visit attendance alone is able to predict almost half of next missed visits. With the addition of baseline demographic and clinical features, this model is able to predict up to 60% of next missed ART visits with a sensitivity of 61.9% (95% CI: 61.5-62.3%), specificity of 66.5% (95% CI: 66.4-66.7%), and positive predictive value of 19.7% (95% CI: 19.5-19.9%). While the full usage of this model is relevant for settings where infrastructure exists to extract EMR data and run computations in real-time, historical visits attendance alone can be used to identify those at risk of disengaging from HIV care in the absence of other behavioural or observable risk factors.

Utilization of antiretroviral therapy services and associated factors among adolescents living with HIV in northern Uganda: A cross-sectional study

BACKGROUND

Suboptimal utilization of antiretroviral therapy (ART) services remains a problem among adolescents in low- and middle-income countries, which has a negative impact on their response to treatment and increases the risk of developing resistance. Optimal use is essential to enhancing treatment efficacy. We investigated the optimal use of ART service and predictors among adolescents living with HIV (ALHIV) in northern Uganda.

METHODS

We used a cross-sectional study design to collect quantitative data from 293 ALHIV at three health facilities in Lira municipality, northern Uganda. We used an interviewer-administered questionnaire and data abstraction form. Data were analysed using SPSS version 23 software. Descriptive analysis and logistic regressions were performed to determine the relationship between the predictor and outcome variables. Statistical significance was determined at P-value<0.05 and the adjusted odds ratio with a 95% confidence interval was used.

RESULTS

The level of utilization of ART services was suboptimal among 27.6% (81/293) of the participants, and only 63.1% (185/293) were virally suppressed. Of the participants who were optimally utilizing ART services, the majority 86.8% (184/212) were virally suppressed. Age 10-14 years (aOR = 3.34), the presence of both parents (aOR = 1.85), parental and peer reminders (aOR = 2.91) and (aOR = 0.49) respectively, and being on ART for five years or less were the characteristics related with optimal utilization of ART services.

CONCLUSIONS AND RECOMMENDATIONS

Not all ALHIV used ART services to their full potential. However, factors such as participants' age, the presence of both parents, reminders from parents and peers, and being on ART for some time were all related to the optimal use of ART services. There is a need for developing strategies to increase family and peer support with a focus on older adolescents if the 95-95-95 goal is to be achieved in this age group.

Clinical outcomes after the introduction of dolutegravir for second-line antiretroviral therapy in South Africa: a retrospective cohort study

Background

Dolutegravir is now recommended for second-line anti-retroviral therapy (ART) in low- and middle-income countries. We compared outcomes with dolutegravir (DTG) versus the previous lopinavir/ritonavir (LPV/r) regimen in South Africa.

Methods

We used routinely collected, de-identified data from 59 South African clinics. We included people living with HIV aged ≥ 15 years with virologic failure (two consecutive viral loads ≥1000 copies/mL) on first-line tenofovir disoproxil fumarate (TDF)-based ART and switched to second-line ART. We used modified Poisson regression models to compare outcomes of 12-month retention-in-care and viral suppression (<50 copies/ml) after switching to second-line regimens of zidovudine (AZT), emtricitabine/lamivudine (XTC), DTG and TDF/XTC/DTG and AZT/XTC/LPV/r.

Findings

Of 1214 participants, 729 (60.0%) were female, median age was 36 years (interquartile range 30 to 42), 689 (56.8%) were switched to AZT/XTC/LPV/r, 217 (17.9%) to AZT/XTC/DTG and 308 (25.4%) to TDF/XTC/DTG. Retention-in-care was higher with AZT/XTC/DTG (85.7%, adjusted risk ratio (aRR) 1.14, 95% confidence interval (CI) 1.03 to 1.27; adjusted risk difference (aRD) 10.89%, 95%CI 2.01 to 19.78) but not different with TDF/XTC/DTG (76.9%, aRR 1.01, 95%CI 0.94 to 1.10; aRD 1.04%, 95%CI -5.03 to 7.12) compared to AZT/XTC/LPV/r (75.2%). Retention-in-care with TDF/XTC/DTG was not statistically significantly different from AZT/XTC/DTG (aRR 0.89, 95%CI 0.78 to 1.01; aRD -9.85%, 95%CI -20.33 to 0.63). Of 799 participants who were retained-in-care with a 12-month viral load, viral suppression was higher with AZT/XTC/DTG (59.3%, aRR 1.25, 95%CI 1.06 to 1.47; aRD 11.57%, 95%CI 2.37 to 20.76) and TDF/XTC/DTG (60.7%, aRR 1.30, 95%CI 1.14 to 1.48; aRD 14.16%, 95%CI 7.14 to 21.18) than with the AZT/XTC/LPV/r regimen (46.7%).

Interpretation

DTG-based second-line regimens were associated with similar or better retention-in-care and better viral suppression than the LPV/r-based regimen. TDF/XTC/DTG had similar viral suppression compared to AZT/XTC/DTG.

Funding

Bill & Melinda Gates Foundation, Africa Oxford Initiative.

Adherence to option B+ PMTCT program and its predictors among HIV-positive women in Ethiopia. A systematic review and meta-analysis

Background

Previously, few studies investigated level of adherence to option B+ lifelong antiretroviral therapy (ART) in Ethiopia. However, their findings were inconsistent. Therefore, this review aimed to determine the pooled magnitude of adherence to option B+ lifelong ART and its predictors among human immune virus (HIV)-positive women in Ethiopia.

Methods

A comprehensive web-based search was conducted using PubMed, Cochrane Library, Science Direct, Google scholar, and African Journals Online databases to retrieve relevant articles. STATA 14 statistical software was used to carry out the meta-analysis. We used the random effects model to account for the large heterogeneity across included studies. Egger's regression test in conjunction with funnel plot and I ² statistics were utilized to assess publication bias and heterogeneity among included studies respectively.

Result

Twelve studies with a total of 2927 study participants were involved in this analysis. The pooled magnitude of adherence to option B+ lifelong ART was 80.72% (95% confidence interval [CI]: 77.05-84.39; I ² = 85.4%). Disclosure of sero-status (OR 2.58 [95% CI: 1.55-4.3]), receiving counseling (OR 4.93 [95% CI: 3.21-7.57]), attending primary school and above (OR 2.45 [95% CI: 1.31-4.57]), partner support (OR 2.24 [95% CI: 1.11, 4.52]), good knowledge about prevention of mother-to-child transmission (PMTCT) (OR 4.22 [95% CI: 2.02-8.84]), taking less time to reach health facility (OR 1.64 [95% CI: 1.13-2.4]), and good relation with care provider (OR 3.24 [95% CI: 1.96-5.34]) were positively associated with adherence. Whereas, fear of stigma and discrimination (OR 0.12 [95% CI: 0.06-0.22]) and advanced disease stage (OR 0.59 [95% CI: 0.37-0.92]) were negatively associated.

Conclusion

The level of adherence to option B+ lifelong ART was suboptimal. Strengthened comprehensive counseling and client education on PMTCT, HIV status disclosure, and male partner involvement are important to eliminate mother to child transmission and control the pandemic.

Perceptions on acceptability of the 2016 WHO ANC model among the pregnant women in Phalombe District, Malawi - a qualitative study using Theoretical Framework of Acceptability

BACKGROUND

The World Health Organization introduced a new model of care, 'The 2016 WHO ANC Model' to overcome challenges encountered during the implementation of the Focused Antenatal Care Approach. For any new intervention to achieve its objective, it must be widely accepted by both the deliverers and recipients. Malawi rolled out the model in 2019 without carrying out acceptability studies. The objective of this study was to explore the perceptions of pregnant women and health care workers on the acceptability of 2016 WHO's ANC model in Phalombe District, Malawi using the Theoretical Framework of Acceptability.

METHODOLOGY

We conducted a descriptive qualitative study between May and August 2021. The Theoretical Framework of Acceptability was used to guide the development of study objectives, data collection tools, and data analysis. We purposely conducted 21 in-depth interviews (IDIs) among pregnant women, postnatal mothers, a safe motherhood coordinator, and Antenatal care (ANC) clinic midwives, and two focus group discussions (FGDs) among Disease Control and Surveillance Assistants. All IDIs and FGDs were conducted in Chichewa, digitally recorded, and simultaneously transcribed and translated into English. Data was analysed manually using content analysis.

RESULTS

The model is acceptable among most pregnant women and they reckoned that it would help reduce maternal and neonatal deaths. Support from a husband, peers, and health care workers facilitated acceptability of the model while the increased number of ANC contacts which resulted in fatigue and increased transportation cost incurred by the women was a deterrent.

CONCLUSION

This study has shown that most pregnant women have accepted the model despite facing numerous challenges. Therefore, there is a need to strengthen the enabling factors and address the bottlenecks in the implementation of the model. Furthermore, the model should be widely publicised so that both intervention deliverers and recipients of care implement the model as intended. This will in turn help to achieve the model's aim of improving maternal and neonatal outcomes and creating a positive experience with health care among pregnant women and adolescent girls.

Factors Associated with Adherence to Treatment in Patients with HIV and Diabetes Mellitus

We aim to identify the factors that influence the therapeutic adherence of subjects with chronic disease. The design followed in this work was empirical, not experimental, and cross-sectional with a correlational objective. The sample consisted of a total of 400 subjects (199 patients with HIV and 201 patients with diabetes mellitus). The instruments applied for data collection were a sociodemographic data questionnaire, the 4-item Morisky Medication Adherence Scale (MMAS-4) and the Coping Strategies Questionnaire. In the group of subjects with HIV, that the use of emotional coping strategies was related to lower adherence to treatment. On the other hand, in the group of subjects with diabetes mellitus, the variable related to compliance with treatment was the duration of illness. Therefore, the predictive factors of adherence to treatment were different in each chronic pathology. In the group of subjects with diabetes mellitus, this variable was related to the duration of the disease. In the group of subjects with HIV, the type of coping strategy used predicted adherence to treatment. As a result of these results, it is possible to develop health programmes to promote, from nursing consultations to adherence to treatment of patients with HIV and diabetes mellitus.

Birth Preparedness Plans and Status Disclosure Among Pregnant Women Living with HIV Who are Receiving Antiretroviral Therapy in Ibadan, Southwest, Nigeria

Background

Promoting the maternal health of pregnant women who are living with human immunodeficiency virus (HIV; [PWLH]) is key to reducing maternal mortality and morbidity. Thus, inadequate birth preparedness plans, non-institutional delivery, and status concealment among PWLH contribute to the spread of HIV infection and threaten the prevention of mother-to-child transmission (PMTCT). Therefore, this study aimed to assess the birth preparedness plan and status disclosure among PWLH, as well as the prevalence of HIV infection among pregnant women.

Methods

The study adopted a descriptive cross-sectional research design; a quantitative approach was used for data collection. Three healthcare facilities that represented the three levels of healthcare institutions and referral centers for the care of PWLH in the Ibadan metropolis were selected for the recruitment process. A validated questionnaire was used to collect data from 77 participants within the targeted population. Ethical approval was obtained prior to the commencement of data collection.

Results

The prevalence rate of HIV infection among the participants was 3.7%. Only 37.1% of the participants had a birth preparedness plan. A total of 40% of the participants tested for HIV, because testing was compulsory for antenatal registration. Only 7.1% of the participants had their status disclosed to their partners. Although 90% of the participants proposed delivering their babies in a hospital, only 80% of these participants had their status known in their proposed place of birth.

Conclusion and Global Health Implications

The prevalence of HIV infection among pregnant women is very low, which is an indication of improved maternal health. However, the level of birth preparedness plan and status disclosure to partners are equally low, and these factors can hinder PMTCT. Institutional delivery should be encouraged among all PWLH, and their HIV status must be disclosed at their place of birth.

Clinical validation of the nursing diagnosis "Ineffective health self-management" in people living with HIV

OBJECTIVE

Check diagnostic accuracy of the defining characteristics of the nursing diagnosis "Ineffective health self-management" in people living with HIV.

METHODS

Methodological study conducted in a specialized public service for people living with HIV in Northeastern Brazil, between February and April 2021, with a sample of 203 people. Latent class analysis was used to calculate the accuracy measurements of the defining characteristics, as well as the sensitivity and specificity values with their respective 95% confidence intervals. The likelihood ratio test (G² ) was applied to evaluate the adequacy of the fit of the models obtained (p > 0.05).

RESULTS

The prevalence of Ineffective health self-management estimated through the latent class model was 67.5%. "Exacerbation of diseases symptoms," "failure to take action that reduces risk factor," "exacerbation of diseases signs," and "ineffective choices in daily living for meeting health goal" had the highest sensitivity values (0.80-0.9429). "Exhibits disease sequelae," "inattentive to diseases signs," and "inattentive to disease symptoms" had the highest specificity values (0.9999-1.0000).

CONCLUSIONS

The useful characteristics for discriminating PLHIV with and without diagnosis are "exacerbation of diseases symptoms," "failure to take action that reduces risk factor," "exacerbation of diseases signs," and "ineffective choices in daily living for meeting health goal." The diagnosis can be confirmed by the indicators "exhibits disease sequelae", "inattentive to diseases signs," and "inattentive to disease symptoms."

IMPLICATIONS FOR NURSING PRACTICES

The study demonstrates the levels of importance of the defining characteristics of "Ineffective health self-management" in people living with HIV contributes to suspicion and accurate diagnostic identification of nurses and researchers.

Review of antiretroviral therapy coverage in 10 highest burden HIV countries in Africa: 2015-2020

Africa is responsible for two-thirds of the global total of new HIV infections. South Africa, Nigeria, Mozambique, Uganda, Tanzania, Zambia, Zimbabwe, Kenya, Malawi, and Ethiopia were responsible for 80% of HIV cases in Africa in 2014 according to the Joint United Nations Programme on HIV/AIDS (UNAIDS). This study assesses antiretroviral coverage strategies implemented by these countries after the initiation of the "Fast-Track strategy to end the AIDS epidemic by 2030." Data reported in this review were obtained from different e-bibliographic including PubMed, Google Scholar, and Research Gate. Key terms were "Antiretroviral therapy," "Antiretroviral treatment," "HIV treatment," "HIV medication," "HIV/AIDS therapy," "HIV/AIDS treatment" + each of the countries listed earlier. We also extracted data on antiretroviral therapy (ART) coverage from the UNAIDS database. About 50 papers published from 2015 to 2021 met the inclusion criteria. All 10 countries have experienced an increase in ART coverage from 2015 to 2020 with an average of 47.6% increment. Nigeria recorded the highest increase in the rate of ART coverage (72% increase) while Ethiopia had the least (30%). New strategies adopted to increase ART coverage and retention in most countries were community-based models and the use of mobile health technology rather than clinic-based. These strategies focus on promoting task shifting, door-to-door access to HIV services, and a long-term supply of antiretroviral medications. Most of these strategies are still in the piloting stage. However, some new strategies and frameworks have been adopted nationwide in countries like Mozambique, Tanzania, Zambia, Zimbabwe, Kenya, and Malawi. Identified challenges include lack of funding, inadequate testing and surveillance services, poor digital penetration, and cultural/religious beliefs. The adoption of community-based and digital health strategies could have contributed to increased ART coverage and retention. African countries should facilitate nationwide scaling of ART coverage strategies to attain the 95-95-95 goal by 2030.

Factors influencing adherence to antiretroviral therapy from the experience of people living with HIV and their healthcare providers in Sierra Leone: a qualitative study

BACKGROUND

Antiretroviral therapy (ART) is the primary mode of treatment for Human Immunodeficiency Virus (HIV). It slows disease progression and reduces the spread of infection. HIV treatment is also known to require a high level of adherence of over 90% to achieve good treatment outcomes and viral load suppression. In Sierra Leone, about 70% of People Living with HIV (PLHIV) are non-adherent in their first year of treatment. Understanding the reasons behind this high rate of non-adherence from the perspectives of both PLHIV and health workers is critical for developing strategies to improve adherence. This qualitative study is rooted in the field of public health services. It identifies the barriers and facilitators influencing adherence to antiretroviral treatment in Sierra Leone.  METHODS: A qualitative study design using in-depth interviews of four healthcare workers and 16 PLHIV in two districts in Sierra Leone- Freetown and Bo. The interviews were analyzed using a grounded theory approach to identify emerging themes from the data.

RESULTS

The study identified several facilitators and barriers to ART adherence at the personal, community, and health system levels. The facilitators included perceived benefits of ART, family support, having an informal caregiver, receiving free ART medicines, and belonging to peer support groups. The identified barriers were stigma and discrimination, frequency of medication, use of traditional medicine, lack of money for food and transport, work barriers, inadequate medicines and test kits, limited health workers, and long distances to clinics.

CONCLUSIONS

Our study emphasized the need for implementing behavioural change communication programmes and activities to reduce stigma and discrimination in the community. Knowledge of the facilitators and barriers to antiretroviral therapy could provide relevant information for more responsive and equitable programmes supporting adherence implementation in low- and middle-income countries. This study also identifies the vital need for community integration of HIV treatment services.

Exploring the barriers to the antiretroviral therapy adherence among people living with HIV in Bangladesh: A qualitative approach

INTRODUCTION

Since the evolution of highly active antiretroviral therapy (ART), a near-perfect ART adherence level (>95%) is needed to control viral suppression. Non-adherence to treatment may lead to acquired immunodeficiency syndrome (AIDS) and drug resistance. Though the Bangladesh government provides free treatment and counselling services to people living with human immunodeficiency virus (PLHIV), only 22% of the identified PLHIV continue treatment. Therefore, this study aims to explore the barriers that obstruct the Bangladeshi PLHIV to ensure ART adherence.

METHODS

We conducted a qualitative study in Dhaka, Bangladesh, and recruited the sensitive study population following non-probability, mainly purposive sampling from a community-based registered organization for PLHIV. We conducted the in-depth interview using a semi-structured guideline with 15 consented respondents. We transcribed the audio-recorded interviews in the local language (Bangla) and then translated those into English for data analysis. During the data extraction process, the lead and corresponding authors independently extracted raw data to generate different themes and sub-themes and invited other authors to contribute when they could not solve any discrepancies.

RESULTS

The study identified three significant categories of barriers at the individual, community, and institutional levels that negatively interfered with ART adherence. The most dominant barriers were discrimination and rejection related to stigma, as almost all participants mentioned these barriers. Stigmatizing attitudes and the discriminatory act of the community people and healthcare providers critically affected their treatment adherence. Other leading barriers were improper inventory management of ART-related medicines and CD4 tests and lack of proper counselling. In addition, we found that a positive approach toward life and family support motivated some respondents to overcome the barriers.

CONCLUSIONS

We recommended strengthening Bangladesh's HIV/AIDS prevention, treatment, and management program with a special focus on the improvement of the supply chain of ART-related medicines and CD4 tests and ensuring proper counselling. In addition, we recommended strengthening the behaviour change communication and IEC activities at a large scale to destigmatize health facilities and community levels.

Adherence to Antiretroviral Therapy in People Living with HIV/AIDS: A Cross-Sectional Study

Adherence to antiretroviral therapy (ART) is essential to suppress HIV replication, preserve immune competence, and ensure quality of life for people living with HIV/AIDS. This is a cross-sectional study to assess adherence to ART in HIV-infected adults and its associated factors in São Carlos, SP, Brazil, from June 2018 to January 2019. Standardized interviews were conducted covering demographic, clinical, and laboratory characteristics and instruments to assess compliance to treatment (CEAT-VIH), HIV/AIDS-targeted quality of life (HAT-QoL), and self-efficacy expectations of adherence (SEA-ART). Each variable was analyzed for association with adherence to ART, by refilling at least 90% of the prescribed doses in the 6 months before the interview date. The study consisted of 220 participants, with a mean age of 43 years, 60.5% male, and 24.5% men who have sex with men. Previous consumption of alcohol or illicit drugs was reported by 44.1% of participants and current or previous smoking by 34.1%. The most common regimen was two nucleoside reverse transcriptase inhibitors combined with one non-nucleoside reverse transcriptase inhibitor (37.3%). The adherence to ART was 62%, and the factors associated with it were living alone [adjusted odds ratio (aOR) 2.79], not having an active sexual life (aOR 0.43), not being a smoker (aOR 0.36), having a CD4 count ≥350 cells/mm³ (aOR 2.50), and having a SEA-ART Score >100 (aOR 1.94). The fear of disclosing HIV status could make adherence to treatment difficult. This could be the reason that living alone and not having an active sexual life have been associated with better adherence. Encouraging healthy lifestyle habits and promoting self-efficacy tools can also improve adherence.

Quality of care in a differentiated HIV service delivery intervention in Tanzania: A mixed-methods study

BACKGROUND

Differentiated service delivery (DSD) offers benefits to people living with HIV (improved access, peer support), and the health system (clinic decongestion, efficient service delivery). ART clubs, 15-30 clients who usually meet within the community, are one of the most common DSD options. However, evidence about the quality of care (QoC) delivered in ART clubs is still limited.

MATERIALS AND METHODS

We conducted a concurrent triangulation mixed-methods study as part of the Test & Treat project in northwest Tanzania. We surveyed QoC among stable clients and health care workers (HCW) comparing between clinics and clubs. Using a Donabedian framework we structured the analysis into three levels of assessment: structure (staff, equipment, supplies, venue), processes (time-spent, screenings, information, HCW-attitude), and outcomes (viral load, CD4 count, retention, self-worth).

RESULTS

We surveyed 629 clients (40% in club) and conducted eight focus group discussions, while 24 HCW (25% in club) were surveyed and 22 individual interviews were conducted. Quantitative results revealed that in terms of structure, clubs fared better than clinics except for perceived adequacy of service delivery venue (94.4% vs 50.0%, p = 0.013). For processes, time spent receiving care was significantly more in clinics than clubs (119.9 vs 49.9 minutes). Regarding outcomes, retention was higher in the clubs (97.6% vs 100%), while the proportion of clients with recent viral load <50 copies/ml was higher in clinics (100% vs 94.4%). Qualitative results indicated that quality care was perceived similarly among clients in clinics and clubs but for different reasons. Clinics were generally perceived as places with expertise and clubs as efficient places with peer support and empathy. In describing QoC, HCW emphasized structure-related attributes while clients focused on processes. Outcomes-related themes such as improved client health status, self-worth, and confidentiality were similarly perceived across clients and HCW.

CONCLUSION

We found better structure and process of care in clubs than clinics with comparable outcomes. While QoC was perceived similarly in clinics and clubs, its meaning was understood differently between clients. DSD catered to the individual needs of clients, either technical care in the clinic or proximate and social care in the club. Our findings highlight that both clinic and DSD care are required as many elements of QoC were individually perceived.

Barriers and Enablers for Adherence to Antiretroviral Therapy Among People Living With HIV/AIDS in the Era of COVID-19: A Qualitative Study From Pakistan

Background: With the increased availability of safe antiretroviral therapy (ART) in recent years, achieving optimal adherence and patient retention is becoming the biggest challenge for people living with HIV (PLWH). Care retention is influenced by several socioeconomic, socio-cultural, and government policies during the COVID-19 pandemic. Therefore, we aim to explore barriers and facilitators to adherence to ART among PLWH in Pakistan in general and COVID-19 pandemic related in particular.

Methods: Semi-structured interviews were conducted among 25 PLWH from December 2020 to April 2021 in the local language (Urdu) at the ART centre of Pakistan Institute of Medical Sciences, Islamabad, Pakistan. Interviews were audio-recorded in the local Urdu language, and bilingual expert (English, Urdu) transcribed verbatim, coded for themes and sub-themes, and analyzed using a phenomenological approach for thematic content analysis.

Results: Stigma and discrimination, fear of HIV disclosure, economic constraints, forgetfulness, religion (Ramadan, spiritual healing), adverse drug reactions, lack of social support, alternative therapies, and COVID-19-related lock-down and fear of lesser COVID-19 care due to HIV associated stigma were identified as barriers affecting the retention in HIV care. At the same time, positive social support, family responsibilities, use of reminders, the beneficial impact of ART, and initiation of telephone consultations, courier delivery, and long-term delivery of antiretrovirals during COVID-19 were identified as facilitators of HIV retention.

Conclusion: Improving adherence and retention is even more challenging due to COVID-19; therefore, it requires the integration of enhanced access to treatment with improved employment and social support. HIV care providers must understand these reported factors comprehensively and treat patients accordingly to ensure the continuum of HIV care. A coordinated approach including different stakeholders is required to facilitate patient retention in HIV care and consequently improve the clinical outcomes of PLWH.

Factors associated with antiretroviral therapy adherence among adolescents living with HIV in the era of isoniazid preventive therapy as part of HIV care

High levels of adherence to antiretroviral therapy (ART) are essential to promoting viral suppression and consequential good treatment outcomes. Adolescents living with HIV (ALHIV) in sub-Saharan Africa are less adherent to ART compared to adults, leading to lower rates of viral suppression and immunological recovery. We conducted a mixed-method study utilizing a convergent parallel approach to explore factors associated with ART adherence among ALHIV in the era of isoniazid preventive therapy (IPT) as part of HIV care. The quantitative data were collected from patient records from the period between 1 February 2017 and 31 January 2018 (6 months before and after IPT introduction), while qualitative data was collected from purposively selected patients and healthcare workers by in-depth interviews through a pretested interview guide. A total of 385 patient records (age 10-19 years) were analyzed in the two time periods, while 16 ALHIV (age 10-19 years) and three healthcare workers directly involved in adolescent care were interviewed. Quantitative data utilized logistic regression to measure the strength of association between IPT addition and ART adherence, whereas, qualitative data were analyzed using a thematic analysis approach. The mean age of participants in the quantitative section was 14.3 years (SD 2.7) and 178 were females, while the median age for adolescents interviewed was 14 (IQR 12-17) and 8 were females. Overall, we found an interaction of factors that influenced ART adherence. Added pill burden, on its own, did not affect ART adherence. Commonly reported factors that led to poor adherence were lack of status disclosure within the family, school pressure, and inadequate support from guardians and parents. According to retrospective patient records, complex ART regimens also worsened adherence (p = 0.0462). ART regimen was independently associated with adherence (OR 2.11 95% CI 0.97-4.53). Being on ART for a longer duration, enrolment into teen clubs, clinical psychosocial support, and self-reinforcement techniques were suggested to improve ART adherence. The interplay of multiple factors leads to poor rates of adherence. The introduction of IPT to ART packages may not independently affect ART adherence. Readily available psychosocial services and the presence of peer and guardian support is critical to optimal ART adherence. There is a need for ART centers that provide HIV care to adolescents to consider integrating psychosocial and other youth-friendly services into day-to-day clinic operations.

Adherence to HIV Antiretroviral Therapy Among Pregnant and Breastfeeding Women, Non-Pregnant Women, and Men in Burkina Faso: Nationwide Analysis 2019-2020

BACKGROUND

Since the scale-up of antiretroviral therapy (ART) services in Burkina-Faso, achieving an AIDS-free generation depends on optimal ART adherence. However, no data exists on the population group differences on the level of ART adherence in Burkina-Faso. This study analyzes ART adherence among pregnant-and breastfeeding-women, non-pregnant women, and men in Burkina-Faso.

METHODS

From December 2019 to March 2020, a cross-sectional study among adult HIV-infected patients in Burkina-Faso, belonging either to the active file or the Prevention of Mother-To-Child Transmission programs was conducted. An analysis was performed and adherence was measured based on the number of times, patients did not meet the number of doses prescribed and did not take the ART treatment in the month prior to the survey. Logistic-regression models were used to identify factors associated with poor ART adherence and the adjusted odds ratios (aORs) with their 95% confidence intervals (95% CI) were reported.

RESULTS

The prevalence of good adherence was higher in the group of pregnant-and breastfeeding-women (86.6%, n = 112) compared to the other groups (73.1%, n=1017 in non-pregnant women and 72.0%, n = 318 in men). No association was found between ART adherence and the socio-demographic, clinical, and therapeutic characteristics of pregnant-and breastfeeding-women and men groups. However, non-pregnant women with a high level of education (aOR = 1.70; 95% CI: 1.16-2.49), having ever belonged to a support group (aOR= 1.47; 95% CI: 1.07-2.04), not having income-generating occupations (aOR= 1.53; 95% CI: 1.11-2.12), and in advanced clinical stage (aOR= 1.42; 95% CI: 1.06-1.91) were more susceptible to have poor adherence compared to their pairs.

CONCLUSION

Findings showed a large difference in ART adherence among pregnant-and breastfeeding-women, non-pregnant women and men and highlight the need for differentiated healthcare delivery according to population while specifically considering addressing the interest in early initiation of treatment and the benefit of support groups meeting.

Patient-Reported Experiences of Medication Adherence at a Community-Based HIV Clinic, Ghana

There is little information on patients’ medication adherence experiences at community-based clinics in Ghana. This study investigated adherence to antiretroviral medication among people living with HIV (PLHIV) attending a community-based HIV clinic. PLHIV (N = 349) completed a questionnaire battery on medication adherence, doctor–patient communication, HIV stigma, patient general self-efficacy, perceived social support, and on patient spirituality. Linear Regression was used to analyze the data. Results showed that doctor–patient communication (β = .38, 95% CI [0.09, 0.18], P <.001) and social support from significant others (β = .46, 95% CI [0.18, 0.67], P <.001) were positively associated with medication adherence in this sample. In contrast, HIV stigma (β = –.16, 95% CI [–0.58, −0.09], P <.01), patient spirituality (β = –.22, 95% CI [–0.44, −0.00], P <.05), and patient general self-efficacy (β = –.14, 95% CI [–0.17, −0.02], P <.01) were negatively associated with medication adherence. There is a need for educational interventions targeted at enhancing doctor–patient communication and social support while reducing stigma among PLHIV in Ghana.

Long-Distance Travel for HIV-Related Care-Burden or Choice?: A Mixed Methods Study in Tanzania

Decentralization of HIV care across sub-Saharan Africa has increased access to anti-retroviral therapy (ART). Although traveling for care has traditionally been viewed as a barrier, some individuals may choose to travel for care due to stigma and fear of HIV status disclosure. We sought to understand the prevalence of traveling long distances for HIV care, as well as reasons for engaging in such travel. Using a concurrent embedded mixed-methods study design, individuals receiving care at two HIV care and treatment clinics in Tanzania completed a quantitative survey (n = 196), and a sub-set of participants reporting long-distance travel for care were interviewed (n = 31). Overall 58.2% of participants (n = 114/196) reported knowing of a closer clinic than the one they chose to attend. Having experienced enacted stigma was significantly associated with traveling for care (OR 2.31, 95% CI 1.12, 4.75, p = 0.02). Reasons for clinic choice centered on three main themes: clinic familiarity, quality of care, and stigma. Traveling for care was often viewed as an enabling strategy for remaining engaged in care by helping overcome other barriers, including stigma and suboptimal quality of care.

<p>Differential Self-Reported Determinants to Antiretroviral Therapy Adherence: Findings from Caregivers of Children Under Five Years Living with Human Immunodeficiency Virus Infection Attending Al-Sabah Hospital, South Sudan</p>

Aim/Objective

This study explored the caregivers’ self-reported determinants of antiretroviral therapy (ART) adherence among children under five years living with human immunodeficiency virus (HIV) infection attending Al-Sabah Hospital, South Sudan.

Methods

A cross-sectional study of 126 caregivers of HIV-infected children under five years was conducted at Al-Sabah Hospital, South Sudan. Data were collected using an interviewer-administered questionnaire. The self-reported adherence was measured as a binary variable using binary logistic regression. Only variables that were significant at bivariate analysis were analyzed at multivariate level and interpreted using the odds ratios (p< 0.05).

Results

Out of 126 caregivers with HIV-infected children, 38 (30.2%) did not adhere to ART. Of the proportion that adhered to ART (88, 69.8%), 49 (55.7%) were male. Most of the children (52, 59.1%) were above two years, but under five years. Fifty (56.8%) of those who adhered had completed 3 months on ART, and the majority were at WHO stage-1 of HIV infection. Analysis of the determinants indicated that children’s duration on ART (p=0.001), type of ART regimen (single, double or triple therapy) (p=0.065), type of work done by the caregiver to earn a living (p-value 0.003), time a child was initiated on ART (p=0.002), caregiver–child relationship (p=0.002), caregiver-spousal support (p=0.019), type of support obtained whether monetary or not (p=0.000), when the child was started on ART (p=0.004), the person administering ART (p=0.010), the type of ARVs administered (p=0.001), the caregiver detecting ART side effects (p=0.000), types of adverse effects suffered by the child (p=0.043), time of receiving ART (p=0.047), use of western medicine (p=0.043), healthcare cadre (p=0.002), the kind of attention the healthcare provider offered (p=0.015), and improvements in quality of HIV services (p=0.001) were significantly associated with ART adherence.

Conclusion

The study findings indicated that ART adherence among HIV-infected children under five years was suboptimal. This will necessitate continuous engagement and education of caregivers on the prominence of adhering to ART.