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Izudi J, Cattamanchi A, Castelnuovo B, King R. Barriers and facilitators to viral load suppression among people living with HIV following intensive adherence counseling in Kampala, Uganda: A qualitative study. Soc Sci Med 2024; 343:116595. [PMID: 38242033 DOI: 10.1016/j.socscimed.2024.116595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 12/08/2023] [Accepted: 01/10/2024] [Indexed: 01/21/2024]
Abstract
We explored the barriers and facilitators to viral load (VL) suppression after three or more intensive adherence counseling (IAC) sessions among adolescents and adults living with human immunodeficiency virus (HIV) on a first-line anti-retroviral therapy (ART) with initially unsuppressed VL in Kampala, Uganda. Using a qualitative study, data were collected through in-depth interviews with people living with HIV (PLHIV) with unsuppressed and suppressed VL and caregivers of younger adolescents living with HIV after three or more IAC sessions. We held key informant interviews with health workers involved in IAC implementation, namely ART/HIV focal persons, IAC Team Leaders, and linkage facilitators. Guided by the socioecological model, we performed content analysis and reported the findings using themes along with the participants' quotes. We studied 24 participants and found the individual-level barriers as forgetting to take HIV medications, high pill burden, medication side effects, a lack of food, and HIV-related psychological distress. Undisclosed HIV status and broken families were the barriers at the interpersonal level. Institutional-level barriers included insufficient HIV and ART counseling. Stigma was considered a community-level barrier while nonadherence to HIV treatment guidelines was a policy-level barrier. Facilitators included personal reminders, knowing the importance of taking treatment, and the ability to deal with side effects of HIV medications at the personal level; treatment support, peer support clubs, and incentivized treatment at the interpersonal level; and mental health support club and explaining during counseling that HIV is a chronic disease at the institutional level. We found an unsuppressed VL after completing IAC was due to several barriers at the personal, interpersonal, health systems, community, and policy levels. Achieving ≥95% VL suppression necessitates tackling the barriers to VL suppression and scaling up the facilitators by HIV control programs.
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Affiliation(s)
- Jonathan Izudi
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Uganda; University of California Global Health Institute (UCGHI), University of California San Francisco, San Francisco, CA, USA.
| | - Adithya Cattamanchi
- Division of Pulmonary Diseases and Critical Care Medicine, University of California Irvine, Irvine, CA, USA
| | - Barbara Castelnuovo
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Uganda
| | - Rachel King
- Institute for Global Health Sciences, Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
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Izudi J, Castelnuovo B, King R, Cattamanchi A. Risk factors for unsuppressed viral load after intensive adherence counseling among HIV infected persons in Kampala, Uganda: a nested case-control study. AIDS Res Ther 2023; 20:90. [PMID: 38110982 PMCID: PMC10729480 DOI: 10.1186/s12981-023-00583-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 11/25/2023] [Indexed: 12/20/2023] Open
Abstract
BACKGROUND Intensive adherence counseling (IAC) is the global standard of care for people living with human immunodeficiency virus (PLHIV) who have unsuppressed VL after ≥ 6 months of first-line anti-retroviral therapy (ART). We investigated whether the number of IAC sessions is associated with suppressed VL among PLHIV in Kampala, Uganda. METHODS We conducted a nested case-control study among PLHIV with unsuppressed VL after ≥ 3 IAC sessions (cases) and a 2:1 random sample of PLHIV with suppressed VL after ≥ 3 IAC sessions (controls). Unsuppressed VL was defined as VL ≥ 1000 copies/ml. We performed multivariable logistic regression to identify factors that differed significantly between cases and controls. RESULTS Demographic and clinical characteristics were similar among the 16 cases and 32 controls including mean age, sex, baseline CD4 count, VL before IAC, and WHO clinical stage. Only the number of IAC sessions differed significantly between cases and controls in unadjusted (p = 0.012) and adjusted (p = 0.016) analyses. Each unit increase in IAC session was associated with unsuppressed VL (Adjusted odds ratio 5.09; 95% CI 1.35-19.10). CONCLUSIONS VL remained unsuppressed despite increasing IAC frequency. The fidelity to standardized IAC protocol besides drug resistance testing among PLHIV with unsuppressed VL before IAC commencement should be examined.
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Affiliation(s)
- Jonathan Izudi
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda.
- University of California Global Health Institute, University of California San Francisco, San Francisco, CA, USA.
| | - Barbara Castelnuovo
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Rachel King
- Department of Epidemiology and Biostatistics, Institute for Global Health Sciences, University of California, San Francisco, San Francisco, CA, USA
| | - Adithya Cattamanchi
- Division of Pulmonary Diseases and Critical Care Medicine, University of California Irvine, Irvine, CA, USA
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Masresha SA, Kidie AA, Alen GD, Mulaw GF, Feleke FW, Kassaw MW, Dejene TM. Virological failure and its predictors among human immunodeficiency virus infected individuals on second line antiretroviral treatment in North-East Ethiopia, 2021. Pharmacoepidemiol Drug Saf 2023; 32:978-987. [PMID: 36974512 DOI: 10.1002/pds.5625] [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: 10/08/2022] [Revised: 02/25/2023] [Accepted: 03/24/2023] [Indexed: 03/29/2023]
Abstract
INTRODUCTION Acquired immune deficiency syndrome (AIDS) becomes a manageable chronic disease due to the presence of effective prevention, diagnosis, treatment, and care accesses. Viral load cascade analyses are important to identify gaps in human immunodeficiency virus (HIV)/AIDS treatment and care for quality improvements. OBJECTIVE Time to Virological Failure and its Predictors among HIV Infected Individuals on Second Line Antiretroviral Treatment (SLART) in North-East Ethiopia, 2021. METHODS Institution-based retrospective follow-up study was conducted on 474 HIV-infected individuals who were on SLART between September 2016 and April 2020. A universal sampling technique was used to recruit study participants. Data were entered by EpiData-3.3.1 and analyzed by STATA-14. Cox proportional hazard assumptions were checked to determine the effect of predictor variables on virological failure (VF). The study was conducted from February 1 to April 30, 2021. RESULTS The rate of VF in this study was 15.4% with an incidence rate of 4.93 per 100 person-years. As participants' age and duration of ART use increased by 1 year the hazards of VF was reduced by 2.9% (AHR: 0.971, 95% CI: 0.945, 0.995) and 10.6% (AHR: 0.894, 95% CI: 0.828, 0.963), respectively. The hazards of VF were twice higher among those who were on a non-protease inhibitor-based regimen. Individuals who had a history of making enhanced adherence counseling (EAC) sessions during SLART had three times more risk to develop VF (AHR: 3.374, 95% CI: 1.790, 6.361). CONCLUSION AND RECOMMENDATIONS The rate of VF among SLART users was high. Keeping SLART users on PI-based regimens may improve virological outcomes in HIV care and treatment. Making EAC sessions effective in promoting better ART adherence might reduce VF.
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Affiliation(s)
| | | | - Gedefaw Diress Alen
- Department of Public Health, Debre Markos University, Debre Markos, Ethiopia
| | | | | | | | - Tadesse Mamo Dejene
- Department of Public Health, Debre Berhan University, Debre Berhan, Ethiopia
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Izudi J, Castelnuovo B, King R, Cattamanchi A. Impact of intensive adherence counseling on viral load suppression and mortality among people living with HIV in Kampala, Uganda: A regression discontinuity design. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0002240. [PMID: 37549128 PMCID: PMC10406184 DOI: 10.1371/journal.pgph.0002240] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 07/13/2023] [Indexed: 08/09/2023]
Abstract
Intensive adherence counseling (IAC) is recommended for people living with HIV (PLHIV) with viral load (VL) ≥1,000 copies/ml after ≥6 months of anti-retroviral therapy (ART). We evaluated the effect of IAC on VL suppression and all-cause mortality among PLHIV on first-line ART with VL ≥1,000 copies/ml after ≥6 months of ART in Kampala, Uganda using regression discontinuity design, a quasi-experimental method for effect estimation when interventions depend on a cut-off. PLHIV just above VL ≥1,000 copies/ml cut-off who received ≥3 IAC sessions formed the intervention group while those just below the cut-off who received routine psychosocial support constituted the control group. Primary outcome was repeat VL suppression defined as VL <1,000 copies/ml approximately 9-12 months following initial VL assessment. Secondary outcome was all-cause mortality. We used logistic regression for causal-effect analysis, reported as odds ratio (OR) with a 95% confidence interval (CI). We performed sensitivity analyses to assess the robustness of findings to varying bandwidths at the cut-off. We found 3,735 PLHIV were started on ART between Nov 2020 and Nov 2021 of whom 3,199 were included in the analysis (3,085 control, 114 intervention). Within an optimal bandwidth, there were 236 participants (222 control, 14 intervention) with similar demographic and clinical characteristics. Repeat VL suppression was lower in the intervention than in the control group (85.7% versus 98.6%, p = 0.021) while all-cause mortality was similar (0% versus 0.5%, p = 1.000). In multivariable analysis, the odds of repeat VL suppression were 91% lower in the intervention than control group (OR = 0.09; 95% CI, 0.01-0.66). Findings are robust to varying bandwidths around the cut-off. We concluded IAC is ineffective in suppressing VL among PLHIV on first-line ART in Kampala, Uganda. Findings suggest a need to investigate the IAC implementation fidelity for successful translation in practice and the reasons for VL persistence beyond the suppression threshold.
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Affiliation(s)
- Jonathan Izudi
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
- University of California Global Health Institute (UCGHI), University of California, San Francisco, San Francisco, CA, United States of America
- African Population and Health Research Center (APHRC), Nairobi, Kenya
| | - Barbara Castelnuovo
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Rachel King
- Institute for Global Health Sciences, Department of Epidemiology and Biostatistics, University of California, San Francisco, California, United States of America
| | - Adithya Cattamanchi
- Center for Tuberculosis, San Francisco General Hospital, University of California, San Francisco, San Francisco, CA, United States of America
- Division of Pulmonary Diseases and Critical Care Medicine, University of California, Irvine, Irvine, CA, United States of America
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Akpan U, Nwanja E, Ukpong KA, Toyo O, Nwaokoro P, Sanwo O, Gana B, Badru T, Idemudia A, Pandey SR, Khamofu H, Bateganya M. Reaching Viral Suppression Among People With HIV With Suspected Treatment Failure who Received Enhanced Adherence Counseling in Southern Nigeria: A Retrospective Analysis. Open Forum Infect Dis 2022; 9:ofac651. [PMID: 36589481 PMCID: PMC9792083 DOI: 10.1093/ofid/ofac651] [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: 10/14/2022] [Indexed: 12/23/2022] Open
Abstract
Background This study assessed viral load (VL) testing and viral suppression following enhanced adherence counseling (EAC) among people with HIV (PWH) with suspected treatment failure and identified factors associated with persistent viremia. Methods We conducted a retrospective review of electronic medical records of PWH aged 15 years or older who had received antiretroviral therapy (ART) for at least 6 months as of December 2020 and had a high viral load (HVL; ≥1000 copies/mL) across 22 comprehensive HIV treatment facilities in Akwa Ibom State, Nigeria. Patients with HVL were expected to receive 3 EAC sessions delivered in person or virtually and repeat VL testing upon completion of EAC and after documented good adherence. At 6 months post-EAC enrollment, we reviewed the data to determine client uptake of 1 or more EAC sessions, completion of 3 EAC sessions, a repeat viral load (VL) test conducted post-EAC, and persistent viremia with a VL of ≥1000 copies/mL. Selected sociodemographic and clinical variables were analyzed to identify factors associated with persistent viremia using SPSS, version 26. Results Of the 3257 unsuppressed PWH, EAC uptake was 94.8% (n = 3088), EAC completion was 81.5% (2517/3088), post-EAC VL testing uptake was 75.9% (2344/3088), and viral resuppression was 73.8% (2280/3088). In multivariable analysis, those on ART for <12 months (P ≤ .001) and those who completed EAC within 3 months (P = .045) were less likely to have persistent viremia. Conclusions An HVL resuppression rate of 74% was achieved, but EAC completion was low. Identification of the challenges faced by PWH with a higher risk of persistent viremia is recommended to optimize the potential benefit of EAC.
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Affiliation(s)
- Uduak Akpan
- Correspondence: Uduak Akpan, 67, Bennett Bassey Street (Unit C), Ewet Housing Estate, Uyo, Akwa Ibom State, Nigeria ()
| | - Esther Nwanja
- Achieving Health Nigeria Initiative (AHNi), Akwa Ibom, Nigeria
| | | | - Otoyo Toyo
- Achieving Health Nigeria Initiative (AHNi), Akwa Ibom, Nigeria
| | | | | | - Bala Gana
- Achieving Health Nigeria Initiative (AHNi), Akwa Ibom, Nigeria
| | - Titilope Badru
- Achieving Health Nigeria Initiative (AHNi), Akwa Ibom, Nigeria
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Beja H, Daisy N, Edek MT, Kobusinge V, Akaki O, Owachgiu IO, Udho S. Barriers and Facilitators to Successful Intensive Adherence Counseling in Rural Northern Uganda: An Exploratory Interview with HIV-Positive Clients Using the COM-B Framework. HIV/AIDS - RESEARCH AND PALLIATIVE CARE 2022; 14:553-563. [DOI: 10.2147/hiv.s393093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 11/16/2022] [Indexed: 11/22/2022]
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