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Filiatreau LM, Ebasone PV, Dzudie A, Wainberg M, Yotebieng M, Anastos K, Parcesepe AM. Intersectional HIV- and Depression-Related Stigma Among People with HIV Entering HIV Care in Cameroon. AIDS Behav 2024:10.1007/s10461-024-04375-2. [PMID: 38767726 DOI: 10.1007/s10461-024-04375-2] [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] [Accepted: 05/08/2024] [Indexed: 05/22/2024]
Abstract
Mental health-related stigma is a prominent barrier to improved mental health outcomes globally and may be particularly harmful to populations with other stigmatized identities. We aimed to understand intersectional depression- and HIV-related stigma among people with HIV (PWH) entering HIV care in Cameroon. Using baseline data from a cohort of PWH entering HIV care in Cameroon between 2019 and 2020, we characterized depression- and HIV-related stigma in the population overall and by sociodemographic sub-group. We also explored substantively meaningful variation in stigma endorsement by depressive symptom severity (Patient Health Questionnaire-9 [PHQ-9]) and causal attribution of depression. Among those with elevated depressive symptoms (PHQ-9 scores > 4), we estimated the association between stigma type and depressive symptom severity using binomial regression. Among 398 participants, 49% endorsed low HIV- and depression-related stigma (N = 195), 10% endorsed high HIV- and depression-related stigma (N = 38), 29% endorsed high depression-related stigma only (N = 116), and 12% endorsed high HIV-related stigma only (N = 49). Respondents with and without heightened depressive symptoms commonly believed depressive symptoms were caused by HIV (N = 140; 32.9%). Among those with elevated depressive symptoms, the prevalence of moderate to severe symptoms was higher among those endorsing high HIV-related stigma only (prevalence ratio 1.55; 95% confidence interval: 1.01, 2.37) compared to those reporting low HIV- and depression-related stigma. HIV- and depression-related stigma are both common among PWH entering HIV care in Cameroon. The consistent association between HIV-related stigma and poor psychosocial well-being among people with HIV necessitates the urgent scale-up of evidence-based HIV-related stigma interventions specifically.
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Affiliation(s)
- Lindsey M Filiatreau
- School of Medicine, Division of Infectious Diseases, Washington University in St. Louis, St. Louis, MO, USA.
| | | | - Anastase Dzudie
- Clinical Research Education Networking and Consultancy, Yaoundé, Cameroon
| | - Milton Wainberg
- Department of Psychiatry, Columbia University and New York State Psychiatric Institute, New York, NY, USA
| | - Marcel Yotebieng
- Department of Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Kathryn Anastos
- Departments of Medicine and Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Angela M Parcesepe
- Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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DeLong SM, Kafu C, Wachira J, Knight JM, Braitstein P, Operario D, Genberg BL. Understanding motivations and resilience-associated factors to promote timely linkage to HIV care: a qualitative study among people living with HIV in western Kenya. AIDS Care 2024; 36:546-552. [PMID: 37499119 DOI: 10.1080/09540121.2023.2240066] [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: 01/04/2022] [Accepted: 07/18/2023] [Indexed: 07/29/2023]
Abstract
Understanding motivations and resilience-associated factors that help people newly diagnosed with HIV link to care is critical in the context of universal test and treat. We analyzed 30 in-depth interviews (IDI) among adults aged 18 and older in western Kenya diagnosed with HIV during home-based counseling and testing and who had linked to HIV care. A directed content analysis was performed, categorizing IDI quotations into a table based on linkage stages for organization and then developing and applying codes from self-determination theory and the concept of resilience. Autonomous motivations, including internalized concerns for one's health and/or to provide care for family, were salient facilitators of accessing care. Controlled forms of motivation, such as fear or external pressure, were less salient. Social support was an important resilience-associated factor fostering linkage. HIV testing and counseling programs which incorporate motivational interviewing that emphasizes motivations related to one's health or family combined with a social support/navigator approach, may promote timely linkage to care.
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Affiliation(s)
- Stephanie M DeLong
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Catherine Kafu
- Behavioral Science Department, School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya
- Academic Model Providing Access to Healthcare (AMPATH) Partnership, Eldoret, Kenya
| | - Juddy Wachira
- Behavioral Science Department, School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya
- Mental Health Department, School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya
| | - Jennifer M Knight
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Paula Braitstein
- Academic Model Providing Access to Healthcare (AMPATH) Partnership, Eldoret, Kenya
- Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Department of Epidemiology and Medical Statistics, School of Public Health, College of Health Sciences, Moi University, Eldoret, Kenya
| | - Don Operario
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, RI, USA
| | - Becky L Genberg
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Naanyu V, Koros H, Goodrich S, Siika A, Toroitich-Ruto C, Bateganya M, Wools-Kaloustian K. Post-intervention perceptions on the antiretroviral therapy community group model in Trans Nzoia County, Kenya. Pan Afr Med J 2024; 47:113. [PMID: 38828427 PMCID: PMC11143075 DOI: 10.11604/pamj.2024.47.113.41843] [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: 09/29/2023] [Accepted: 02/19/2024] [Indexed: 06/05/2024] Open
Abstract
Introduction the increasing number of people receiving antiretroviral therapy (ART) in sub-Saharan Africa has stressed already overburdened health systems. A care model utilizing community-based peer-groups (ART Co-ops) facilitated by community health workers (CHW) was implemented (2016-2018) to address these challenges. In 2018, a post-intervention study assessed perceptions of the intervention. Methods forty participants were engaged in focus group discussions consisting of ART Co-op clients, study staff, and health care providers from Kitale HIV clinic. Data were analyzed thematically for content on the intervention, challenges, and recommendations for improvement. Results all participants liked the intervention. However, some reported traveling long distances to attend ART Co-op meetings and experiencing stigma with ART Co-ops participation. The ART Co-op inclusion criteria were considered appropriate; however, additional outreach to deliberately include spouses living with HIV, the disabled, the poor, and HIV pregnant women was recommended. Participants liked CHW-directed quarterly group meetings which included ART distribution, adherence review, and illness identification. The inability of the CHW to provide full clinical care, inconvenient meeting venues, poor timekeeping, and non-attendance behaviors were noted as issues. Participants indicated that program continuation, regular CHW training, rotating meetings at group members´ homes, training ART Co-ops leaders to assume CHW tasks, use of pill diaries to check adherence, nutritional support, and economically empowering members through income generation projects would be beneficial. Conclusion the intervention was viewed positively by both clinic staff and clients. They identified specific challenges and generated actionable key considerations to improve access and acceptability of the community-based model of care.
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Affiliation(s)
- Violet Naanyu
- Department of Sociology Psychology and Anthropology, School of Arts and Social Sciences, Moi University, Eldoret, Kenya
- AMPATH Qualitative Research Core, Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | - Hillary Koros
- AMPATH Qualitative Research Core, Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | - Suzanne Goodrich
- Division of Infectious Diseases, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Abraham Siika
- Department of Medicine, School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya
| | - Cathy Toroitich-Ruto
- Division of Global HIV and TB (DGHT), Centers for Global Health (CGH), US Centers for Disease Control and Prevention (CDC), Nairobi, Kenya
| | | | - Kara Wools-Kaloustian
- Division of Infectious Diseases, Indiana University School of Medicine, Indianapolis, IN, USA
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Rosen JG, Nakyanjo N, Ddaaki WG, Zhao T, Van Vo A, Nakubulwa R, Ssekyewa C, Isabirye D, Katono RL, Nabakka P, Ssemwanga RJ, Kigozi G, Odiya S, Nakigozi G, Nalugoda F, Kigozi G, Kagaayi J, Grabowski MK, Kennedy CE. Identifying longitudinal patterns of HIV treatment (dis)engagement and re-engagement from oral histories of virologically unsuppressed persons in Uganda: A thematic trajectory analysis. Soc Sci Med 2023; 339:116386. [PMID: 37984182 PMCID: PMC10841599 DOI: 10.1016/j.socscimed.2023.116386] [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: 04/06/2023] [Revised: 10/01/2023] [Accepted: 10/28/2023] [Indexed: 11/22/2023]
Abstract
BACKGROUND There is limited study of persons deemed "harder to reach" by HIV treatment services, including those discontinuing or never initiating antiretroviral therapy (ART). We conducted narrative research in southern Uganda with virologically unsuppressed persons identified through population-based sampling to discern longitudinal patterns in HIV service engagement and identify factors shaping treatment persistence. METHODS In mid-2022, we sampled adult participants with high-level HIV viremia (≥1000 RNA copies/mL) from the prospective, population-based Rakai Community Cohort Study. Using life history calendars, we conducted initial and follow-up in-depth interviews to elicit oral histories of participants' journeys in HIV care, from diagnosis to the present. We then used thematic trajectory analysis to identify discrete archetypes of HIV treatment engagement by "re-storying" participant narratives and visualizing HIV treatment timelines derived from interviews and abstracted clinical data. RESULTS Thirty-eight participants (median age: 34 years, 68% men) completed 75 interviews. We identified six HIV care engagement archetypes from narrative timelines: (1) delayed ART initiation, (2) early treatment discontinuation, (3) treatment cycling, (4) prolonged treatment interruption, (5) transfer-related care disruption, and (6) episodic viremia. Patterns of service (dis)engagement were highly gendered, occurred in the presence and absence of optimal ART adherence, and were shaped by various factors emerging at different time points, including: denial of HIV serostatus and disclosure concerns; worsening HIV-related symptoms; psychological distress and depression; social support; intimate partner violence; ART side effects; accessibility constraints during periods of mobility; incarceration; and inflexible ART dispensing regulations. CONCLUSIONS Identified trajectories uncovered heterogeneities in both the timing and drivers of ART (re-)initiation and (dis)continuity, demonstrating the distinct characteristics and needs of people with different patterns of HIV treatment engagement throughout the life course. Enhanced mental health service provision, expanded eligibility for differentiated service delivery models, and streamlined facility switching processes may facilitate timely (re-)engagement in HIV services.
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Affiliation(s)
- Joseph G Rosen
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA.
| | | | | | - Tongying Zhao
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Anh Van Vo
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | | | | | | | | | | | | | | | - Silas Odiya
- Rakai Health Sciences Program, Entebbe, Uganda
| | | | | | | | | | - M Kate Grabowski
- Rakai Health Sciences Program, Entebbe, Uganda; Division of Pathology, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Caitlin E Kennedy
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA; Rakai Health Sciences Program, Entebbe, Uganda
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Dhairyawan R, Milner A, Thornhill JP, Kwardem L, Matin N, Orkin C, Deane K. Experiences of initiating rapid antiretroviral therapy among people newly diagnosed with HIV in East London: a qualitative study. Sex Transm Infect 2023; 99:455-460. [PMID: 37068829 DOI: 10.1136/sextrans-2022-055682] [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: 11/02/2022] [Accepted: 04/01/2023] [Indexed: 04/19/2023] Open
Abstract
OBJECTIVES We aimed to explore the experiences of people who initiated rapid antiretroviral therapy (ART) within 7 days of HIV diagnosis, as part of routine care in London. METHODS Using purposive sampling, 18 in-depth, semistructured interviews were conducted between December 2020 and September 2021 with people who started rapid ART at Barts Health NHS Trust. Participants aged 22-69 years included 15 cisgender men and three cisgender women. Five identified as heterosexual and 13 as gay and bisexual and other men who have sex with men. Ethnic identities: six White Non-UK, five White UK, three Black Caribbean, two South Asian and two East Asian. Interviews explored feelings about the new HIV diagnosis, attitudes to rapid ART including barriers to and facilitators of starting. Thematic analysis of transcribed interviews was undertaken. RESULTS Four themes were identified: (1) being offered rapid ART is acceptable; (2) it is a way of taking control of their health; (3) the need for information and support and (4) an individualised approach to care. Reasons for starting included getting well, staying well and reducing the likelihood of passing on HIV. Facilitators included being given comprehensive information about treatment and managing potential side-effects and a supportive clinical team. Support specified included a non-judgemental attitude, approachability, reassurance, encouragement and information about peer support. Most participants expressed they could not understand why people would not begin treatment, but suggested needing more time to decide and denial of diagnosis as possible barriers. CONCLUSIONS To our knowledge, this is the first qualitative study exploring the experiences of people initiating rapid ART in the UK. It was deemed acceptable to an ethnically diverse, predominantly male sample of people newly diagnosed with HIV. Future research should include strategies to recruit a more gender diverse sample and those who declined or stopped rapid ART.
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Affiliation(s)
- Rageshri Dhairyawan
- Infection and Immunity, Barts Health NHS Trust, London, UK
- SHARE Collaborative, Queen Mary University of London, London, UK
| | | | - John P Thornhill
- Infection and Immunity, Barts Health NHS Trust, London, UK
- SHARE Collaborative, Queen Mary University of London, London, UK
| | | | - Nashaba Matin
- Infection and Immunity, Barts Health NHS Trust, London, UK
| | - Chloe Orkin
- Infection and Immunity, Barts Health NHS Trust, London, UK
- SHARE Collaborative, Queen Mary University of London, London, UK
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OUÉDRAOGO SMAÏLA, DAH TERTIEROELIAS, DIALLO ISMAËL, SARIGDA MAURICE, DAHOUROU DÉSIRÉLUCIEN, ROMBA ISSA, SANON FATOGOMABERTRAND, KABORE PENGDWENDÉANNELYGIE, YONLI BAPOUGOUNIPHILIPPECHRISTIAN, SAVADOGO LÉONGUESWENDÉBLAISE. Sub-optimal satisfaction of people living with HIV and AIDS regarding their care in Burkina Faso, West Africa. J Public Health Afr 2023; 14:2432. [PMID: 37908387 PMCID: PMC10615165 DOI: 10.4081/jphia.2023.2432] [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: 12/05/2022] [Accepted: 05/16/2023] [Indexed: 11/02/2023] Open
Abstract
People living with HIV (PLHIV) satisfaction regarding to care could play an important role in the elimination of HIV epidemic by 2030. We assessed Burkina Faso PLHIV satisfaction regarding to their care, and identified its associated factors. A representative nationwide cross-sectional study was performed in 2021-2022 in 30 HIV/AIDS care sites. PLHIV aged at least 18 years, receiving ART for six months or plus were included. Individual and structural data were collected using a questionnaire administered by trained investigators. Satisfaction with HIV/AIDS care was explored using six components (reception, waiting time to medical visit, care environment, sharing updated information on HIV AIDS, answering to PLHIV questions, and providing tailored care and advice to PLHIV needs). Factors associated with satisfaction were identified using logistic regressions. 448 PLHIV were considered in this analysis. Median age was 46 years. Overall satisfaction regarding to care was 40,8% (95% confidence interval 95% CI 36.2-45.6). Specifically, it was 90.6, 54.9, 85.3, 75.7, 90.8, and 93.3% regarding to reception, waiting time, care environment, sharing updated information, answering to PLHIV questions, and providing tailored care and advice to PLHIV needs, respectively. Attending to medical visits in community-based organization (CBO) and private clinics (adjusted odds ratio aOR 1.82, 95% CI 1.14-2.93, P#x003C;0.001), as well as in tertiary hospitals (aOR 2.37, 95% CI 1.45-3.87, P=0.001) were positively associated with PLHIV satisfaction. Burkina Faso PLHIV are generally unsatisfied with care. HIV national authorities should promote HIV care in CBO clinics model in the delivery of HIV services in others public sites.
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Affiliation(s)
- SMAÏLA OUÉDRAOGO
- Department of Public Health, Health Sciences Training and Research Unit, Université Joseph Ki-Zerbo, Ouagadougou
| | | | - ISMAËL DIALLO
- Department of Medicine and Medical Specialties, Université Joseph Ki-Zerbo, Ouagadougou
| | - MAURICE SARIGDA
- Department of Sociology, Human Sciences, Université Thomas Sankara, Ouagadougou
| | - DÉSIRÉ LUCIEN DAHOUROU
- Biomedical/Public Health Department, Health Sciences Research Institute, National Center for Scientific and Technologic Research, Ouagadougou
| | - ISSA ROMBA
- Permanant secretary office of the national council responding to HIV/AIDS and sexually transmitted diseases, Ouagadougou
| | - FATOGOMA BERTRAND SANON
- Department of Public Health, Health Sciences Training and Research Unit, Université Joseph Ki-Zerbo, Ouagadougou
| | - PENGDWENDÉ ANNE LYGIE KABORE
- Department of Public Health, Health Sciences Training and Research Unit, Université Joseph Ki-Zerbo, Ouagadougou
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Kim GS, Kim L, Shim MS, Baek S, Kim N, Park MK, Lee Y. [Psychometric Properties of the Korean Version of Self-Efficacy for HIV Disease Management Skills]. J Korean Acad Nurs 2023; 53:295-308. [PMID: 37435761 DOI: 10.4040/jkan.23016] [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: 02/08/2023] [Revised: 04/17/2023] [Accepted: 05/22/2023] [Indexed: 07/13/2023]
Abstract
PURPOSE This study evaluated the validity and reliability of Shively and colleagues' self-efficacy for HIV disease management skills (HIV-SE) among Korean participants. METHODS The original HIV-SE questionnaire, comprising 34 items, was translated into Korean using a translation and back-translation process. To enhance clarity and eliminate redundancy, the author and expert committee engaged in multiple discussions and integrated two items with similar meanings into a single item. Further, four HIV nurse experts tested content validity. Survey data were collected from 227 individuals diagnosed with HIV from five Korean hospitals. Construct validity was verified through confirmatory factor analysis. Criterion validity was evaluated using Pearson's correlation coefficients with the new general self-efficacy scale. Internal consistency reliability and test-retest were examined for reliability. RESULTS The Korean version of HIV-SE (K-HIV-SE) comprises 33 items across six domains: "managing depression/mood," "managing medications," "managing symptoms," "communicating with a healthcare provider," "getting support/help," and "managing fatigue." The fitness of the modified model was acceptable (minimum value of the discrepancy function/degree of freedom = 2.49, root mean square error of approximation = .08, goodness-of-fit index = .76, adjusted goodness-of-fit index = .71, Tucker-Lewis index = .84, and comparative fit index = .86). The internal consistency reliability (Cronbach's α = .91) and test-retest reliability (intraclass correlation coefficient = .73) were good. The criterion validity of the K-HIV-SE was .59 (p < .001). CONCLUSION This study suggests that the K-HIV-SE is useful for efficiently assessing self-efficacy for HIV disease management.
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Affiliation(s)
- Gwang Suk Kim
- College of Nursing, Yonsei University, Seoul, Korea
- Mo-Im Kim Nursing Research Institute, Yonsei University, Seoul, Korea
| | - Layoung Kim
- College of Nursing, Yonsei University, Seoul, Korea
- Mo-Im Kim Nursing Research Institute, Yonsei University, Seoul, Korea
- S-L.E.A.P Global Nurse Scientist Program, College of Nursing and Brain Korea 21 FOUR Project, Yonsei University, Seoul, Korea
| | - Mi-So Shim
- College of Nursing, Keimyung University, Daegu, Korea
| | | | - Namhee Kim
- Wonju College of Nursing, Yonsei University, Wonju, Korea
| | - Min Kyung Park
- College of Nursing, Yonsei University, Seoul, Korea
- National Police Hospital, Seoul, Korea
| | - Youngjin Lee
- S-L.E.A.P Global Nurse Scientist Program, College of Nursing and Brain Korea 21 FOUR Project, Yonsei University, Seoul, Korea.
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Kafu C, Wachira J, Omodi V, Said J, Pastakia SD, Tran DN, Onyango JA, Aburi D, Wilson-Barthes M, Galárraga O, Genberg BL. Integrating community-based HIV and non-communicable disease care with microfinance groups: a feasibility study in Western Kenya. Pilot Feasibility Stud 2022; 8:266. [PMID: 36578093 PMCID: PMC9795156 DOI: 10.1186/s40814-022-01218-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 11/29/2022] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND The Harambee study is a cluster randomized trial in Western Kenya that tests the effect, mechanisms, and cost-effectiveness of integrating community-based HIV and non-communicable disease care within microfinance groups on chronic disease treatment outcomes. This paper documents the stages of our feasibility study conducted in preparation for the Harambee trial, which include (1) characterizing the target population and gauging recruitment capacity, (2) determining community acceptability of the integrated intervention and study procedures, and (3) identifying key implementation considerations prior to study start. METHODS Feasibility research took place between November 2019 and February 2020 in Western Kenya. Mixed methods data collection included surveys administered to 115 leaders of 105 community-based microfinance groups, 7 in-person meetings and two workshops with stakeholders from multiple sectors of the health system, and ascertainment of field notes and geographic coordinates for group meeting locations and HIV healthcare facilities. Quantitative survey data were analyzed using STATA IC/13. Longitude and latitude coordinates were mapped to county boundaries using Esri ArcMap. Qualitative data obtained from stakeholder meetings and field notes were analyzed thematically. RESULTS Of the 105 surveyed microfinance groups, 77 met eligibility criteria. Eligible groups had been in existence from 6 months to 18 years and had an average of 22 members. The majority (64%) of groups had at least one member who owned a smartphone. The definition of "active" membership and model of saving and lending differed across groups. Stakeholders perceived the community-based intervention and trial procedures to be acceptable given the minimal risks to participants and the potential to improve HIV treatment outcomes while facilitating care integration. Potential challenges identified by stakeholders included possible conflicts between the trial and existing community-based interventions, fear of group disintegration prior to trial end, clinicians' inability to draw blood for viral load testing in the community, and deviations from standard care protocols. CONCLUSIONS This study revealed that it was feasible to recruit the number of microfinance groups necessary to ensure that our clinical trial was sufficient powered. Elicitation of stakeholder feedback confirmed that the planned intervention was largely acceptable and was critical to identifying challenges prior to implementation. TRIAL REGISTRATION The original trial was prospectively registered with ClinicalTrials.gov (NCT04417127) on 4 June 2020.
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Affiliation(s)
- Catherine Kafu
- Academic Model Providing Access to Healthcare, P.O. Box 4606-30100, Eldoret, Kenya. .,School of Literature, Language and Media, Department of Media Studies, University of Witwatersrand, 1 Jan Smuts Avenue, Braamfontein, Johannesburg, 2000, South Africa.
| | - Juddy Wachira
- grid.512535.50000 0004 4687 6948Academic Model Providing Access to Healthcare, P.O. Box 4606-30100, Eldoret, Kenya ,grid.79730.3a0000 0001 0495 4256School of Medicine, Department of Behavioral Science, Moi University College of Health Sciences, P.O. Box 4606-30100, Eldoret, Kenya
| | - Victor Omodi
- grid.512535.50000 0004 4687 6948Academic Model Providing Access to Healthcare, P.O. Box 4606-30100, Eldoret, Kenya
| | - Jamil Said
- grid.512535.50000 0004 4687 6948Academic Model Providing Access to Healthcare, P.O. Box 4606-30100, Eldoret, Kenya ,grid.79730.3a0000 0001 0495 4256School of Medicine, Department of Human Anatomy, Moi University College of Health Sciences, P.O. Box 4606-30100, Eldoret, Kenya
| | - Sonak D. Pastakia
- grid.512535.50000 0004 4687 6948Academic Model Providing Access to Healthcare, P.O. Box 4606-30100, Eldoret, Kenya ,grid.169077.e0000 0004 1937 2197Center for Health Equity and Innovation, Purdue University College of Pharmacy, 640 Eskenazi Ave, Indianapolis, IN 46202 USA
| | - Dan N. Tran
- grid.512535.50000 0004 4687 6948Academic Model Providing Access to Healthcare, P.O. Box 4606-30100, Eldoret, Kenya ,grid.264727.20000 0001 2248 3398Department of Pharmacy Practice, Temple University School of Pharmacy, 3307 N Broad St, Philadelphia, PA 19140 USA
| | - Jael Adongo Onyango
- grid.512535.50000 0004 4687 6948Academic Model Providing Access to Healthcare, P.O. Box 4606-30100, Eldoret, Kenya
| | - Dan Aburi
- grid.512535.50000 0004 4687 6948Academic Model Providing Access to Healthcare, P.O. Box 4606-30100, Eldoret, Kenya
| | - Marta Wilson-Barthes
- grid.40263.330000 0004 1936 9094Department of Epidemiology, Brown University School of Public Health, 121 South Main Street, Providence, RI 02912 USA
| | - Omar Galárraga
- grid.40263.330000 0004 1936 9094Department of Health Services, Policy and Practice, Brown University School of Public Health, 121 South Main Street, Providence, RI 02912 USA
| | - Becky Lynn Genberg
- grid.21107.350000 0001 2171 9311Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205 USA
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Wachira J, Mwangi A, Genberg B, Ngeresa A, Galárraga O, Kimayo S, Dick J, Braitstein P, Wilson I, Hogan J. Continuity of Care is Associated with Higher Appointment Adherence Among HIV Patients in Low Clinician-to-Patient Ratio Facilities in Western Kenya. AIDS Behav 2022; 26:3516-3523. [PMID: 35467227 DOI: 10.1007/s10461-022-03686-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/06/2022] [Indexed: 11/27/2022]
Abstract
We sought to determine the relationship between continuity of care and adherence to clinic appointments among patients receiving HIV care in high vs. low clinician-to-patient (C:P) ratios facilities in western Kenya. This retrospective analysis included 12,751 patients receiving HIV care from the Academic Model Providing Access to Healthcare (AMPATH) program, between February 2016-2019. We used logistic regression analysis with generalized estimating equations to estimate the relationship between continuity of care (two consecutive visits with the same provider) and adherence to clinic appointments (within 7 days of a scheduled appointment) over time. Adjusting for covariates, patients in low C:P ratio facilities who had continuity of care, were more likely to be adherent to their appointments compared to those without continuity (adjusted odds ratio = 1.50; 95% confidence interval, 1.33-1.69). Continuity in HIV care may be a factor in clinical adherence among patients in low C:P ratio facilities and should therefore be promoted.
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Affiliation(s)
- Juddy Wachira
- Department of Mental Health & Behavioral Sciences, School of Medicine, College of Health Sciences, Moi University Eldoret, P.O Box 4604-30100, Eldoret, Kenya.
- Department of Media Studies, School of Literature, Language and Media, University of Witwatersrand, Johannesburg, South Africa.
| | - Ann Mwangi
- Department of Maths, Physics and Computing, School of Science and Aerospace Studies, Moi University, Eldoret, Kenya
| | - Becky Genberg
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Anthony Ngeresa
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | - Omar Galárraga
- Department of Health Services, Policy & Practice, School of Public Health, Brown University, Providence, RI, USA
| | - Sylvester Kimayo
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
- Department of Medicine, School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya
| | - Jonathan Dick
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | - Paula Braitstein
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Ira Wilson
- Department of Health Services, Policy & Practice, School of Public Health, Brown University, Providence, RI, USA
| | - Joseph Hogan
- Department of Biostatistics, School of Public Health, Brown University, Providence, RI, USA
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10
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Wada PY, Kim A, Jayathilake K, Duda SN, Abo Y, Althoff KN, Cornell M, Musick B, Brown S, Sohn AH, Chan YJ, Wools-Kaloustian KK, Nash D, Yiannoutsos CT, Cesar C, McGowan CC, Rebeiro PF. Site-Level Comprehensiveness of Care Is Associated with Individual Clinical Retention Among Adults Living with HIV in International Epidemiology Databases to Evaluate AIDS, a Global HIV Cohort Collaboration, 2000-2016. AIDS Patient Care STDS 2022; 36:343-355. [PMID: 36037010 PMCID: PMC9514598 DOI: 10.1089/apc.2022.0042] [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] [Indexed: 01/29/2023] Open
Abstract
Retention in care (RIC) reduces HIV transmission and associated morbidity and mortality. We examined whether delivery of comprehensive services influenced individual RIC within the International epidemiology Databases to Evaluate AIDS (IeDEA) network. We collected site data through IeDEA assessments 1.0 (2000-2009) and 2.0 (2010-2016). Each site received a comprehensiveness score for service availability (1 = present, 0 = absent), with tallies ranging from 0 to 7. We obtained individual-level cohort data for adults with at least one visit from 2000 to 2016 at sites responding to either assessment. Person-time was recorded annually, with RIC defined as completing two visits at least 90 days apart in each calendar year. Multivariable modified Poisson regression clustered by site yielded risk ratios and predicted probabilities for individual RIC by comprehensiveness. Among 347,060 individuals in care at 122 sites with 1,619,558 person-years of follow-up, 69.8% of person-time was retained in care, varying by region from 53.8% (Asia-Pacific) to 82.7% (East Africa); RIC improved by about 2% per year from 2000 to 2016 (p = 0.012). Every site provided CD4+ count testing, and >90% of individuals received care at sites that provided combination antiretroviral therapy adherence measures, prevention of mother-to-child transmission, tuberculosis screening, HIV-related prevention, and community tracing services. In adjusted models, individuals at sites with more comprehensive services had higher probabilities of RIC (0.71, 0.74, and 0.83 for scores 5, 6, and 7, respectively; p = 0.019). Within IeDEA, greater site-level comprehensiveness of services was associated with improved individual RIC. Much work remains in exploring this relationship, which may inform HIV clinical practice and health systems planning.
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Affiliation(s)
- Paul Y. Wada
- Division of Infectious Diseases, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Ahra Kim
- Division of Infectious Diseases, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Karu Jayathilake
- Division of Infectious Diseases, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Stephany N. Duda
- Division of Infectious Diseases, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Yao Abo
- Centre Médical de Suivi des Donneurs de Sang (CMSDS), Centre National de Transfusion Sanguine, Abidjan, Côte d'Ivoire
| | - Keri N. Althoff
- Division of Epidemiology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Morna Cornell
- Center for Infectious Disease Epidemiology & Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Beverly Musick
- Division of Biostatistics and Infectious Diseases, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Steve Brown
- Division of Biostatistics and Infectious Diseases, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Annette H. Sohn
- Division of Pediatrics, University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Yu Jiun Chan
- Taipei Veterans General Hospital, Taipei, Taiwan
| | - Kara K. Wools-Kaloustian
- Division of Biostatistics and Infectious Diseases, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Denis Nash
- Division of Epidemiology and Biostatistics, City University of New York, Institute for Implementation Science in Population Health, New York, New York, USA
| | - Constantin T. Yiannoutsos
- Division of Biostatistics, Indiana University Fairbanks School of Public Health, Indianapolis, Indiana, USA
| | | | - Catherine C. McGowan
- Division of Infectious Diseases, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Peter F. Rebeiro
- Division of Infectious Diseases, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
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11
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Wachira J, Genberg B, Mwangi A, Chemutai D, Braitstein P, Galarraga O, Abraham S, Wilson I. Impact of an Enhanced Patient Care Intervention on Viral Suppression Among Patients Living With HIV in Kenya. J Acquir Immune Defic Syndr 2022; 90:434-439. [PMID: 35320121 PMCID: PMC9246844 DOI: 10.1097/qai.0000000000002987] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Accepted: 03/03/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Effective patient-centered interventions are needed to promote patient engagement in HIV care. We assessed the impact of a patient-centered intervention referred to as enhanced patient care (EPC) on viral suppression among unsuppressed patients living with HIV in Kenya. SETTING Two rural HIV clinics within the Academic Model Providing Access to Health care. METHODS This was a 6-month pilot randomized control trial. The EPC intervention incorporated continuity of clinician-patient relationships, enhanced treatment dialog, and improved patients' clinic appointment scheduling. Provider-patient communication training was offered to all clinicians in the intervention site. We targeted 360 virally unsuppressed patients: (1) 240 in the intervention site with 120 randomly assigned to provider-patient communication (PPC) training + EPC and 120 to PPC training + standard of care (SOC) and (2) 120 in the control site receiving SOC. Logistic regression analysis was applied using R (version 3.6.3). RESULTS A total of 328 patients were enrolled: 110 (92%) PPC training + EPC, 110 (92%) PPC training + SOC, and 108 (90%) SOC. Participants' mean age at baseline was 48 years (SD: 12.05 years). Viral suppression 6 months postintervention was 84.4% among those in PPC training + EPC, 83.7% in PPC training + SOC, and 64.4% in SOC ( P ≤ 0.001). Compared with participants in PPC training + EPC, those in SOC had lower odds of being virally suppressed 6 months postintervention (odds ratio = 0.36, 95% confidence interval: 0.18 to 0.72). CONCLUSIONS PPC training may have had the greatest impact on patient viral suppression. Hence, adequate training and effective PPC implementation strategies are needed.
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Affiliation(s)
- Juddy Wachira
- Department of Behavioral Sciences, School of Medicine, College of Health Sciences, Moi University Eldoret, Kenya
- Department of Media Studies, School of Literature, Language and Media, University of Witwatersrand, Johannesburg, South Africa
| | - Becky Genberg
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore MD, USA
| | - Ann Mwangi
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
- Institute of Biomedical Informatics, College of Health Sciences, Moi University, Eldoret, Kenya
| | - Diana Chemutai
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | - Paula Braitstein
- Dalla Lana School of Public Health, University of Toronto, Ontario, Canada
| | - Omar Galarraga
- Department of Health Services, Policy & Practice, School of Public Health, Brown University, Providence, RI, USA
| | - Siika Abraham
- Department of Medicine, School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya
| | - Ira Wilson
- Department of Health Services, Policy & Practice, School of Public Health, Brown University, Providence, RI, USA
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12
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Golub SA, Fikslin RA. Recognizing and disrupting stigma in implementation of HIV prevention and care: a call to research and action. J Int AIDS Soc 2022; 25 Suppl 1:e25930. [PMID: 35818865 PMCID: PMC9274207 DOI: 10.1002/jia2.25930] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 05/04/2022] [Indexed: 01/14/2023] Open
Abstract
INTRODUCTION There is robust evidence that stigma negatively impacts both people living with HIV and those who might benefit from HIV prevention interventions. Within healthcare settings, research on HIV stigma has focused on intra-personal processes (i.e. knowledge or internalization of community-level stigma that might limit clients' engagement in care) or inter-personal processes (i.e. stigmatized interactions with service providers). Intersectional approaches to stigma call us to examine the ways that intersecting systems of power and oppression produce stigma not only at the individual and interpersonal levels, but also within healthcare service delivery systems. This commentary argues for the importance of analysing and disrupting the way in which stigma may be (intentionally or unintentionally) enacted and sustained within HIV service implementation, that is the policies, protocols and strategies used to deliver HIV prevention and care. We contend that as HIV researchers and practitioners, we have failed to fully specify or examine the mechanisms through which HIV service implementation itself may reinforce stigma and perpetuate inequity. DISCUSSION We apply Link and Phelan's five stigma components (labelling, stereotyping, separation, status loss and discrimination) as a framework for analysing the way in which stigma manifests in existing service implementation and for evaluating new HIV implementation strategies. We present three examples of common HIV service implementation strategies and consider their potential to activate stigma components, with particular attention to how our understanding of these dynamics can be enhanced and expanded by the application of intersectional perspectives. We then provide a set of sample questions that can be used to develop and test novel implementation strategies designed to mitigate against HIV-specific and intersectional stigma. CONCLUSIONS This commentary is a theory-informed call to action for the assessment of existing HIV service implementation, for the development of new stigma-reducing implementation strategies and for the explicit inclusion of stigma reduction as a core outcome in implementation research and evaluation. We argue that these strategies have the potential to make critical contributions to our ability to address many system-level form stigmas that undermine health and wellbeing for people living with HIV and those in need of HIV prevention services.
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Affiliation(s)
- Sarit A Golub
- Department of Psychology, Hunter College, New York, New York, USA.,Basic and Applied Social Psychology, The Graduate Center of the City University of New York, New York, New York, USA.,Hunter Alliance for Research and Translation, Hunter College, New York, New York, USA.,Einstein-Rockefeller-CUNY Center for AIDS Research (ERC-CFAR), New York, New York, USA
| | - Rachel A Fikslin
- Department of Psychology, Hunter College, New York, New York, USA.,Basic and Applied Social Psychology, The Graduate Center of the City University of New York, New York, New York, USA.,Hunter Alliance for Research and Translation, Hunter College, New York, New York, USA
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13
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Samba BO, Lewis-Kulzer J, Odhiambo F, Juma E, Mulwa E, Kadima J, Bukusi EA, Cohen CR. Exploring Estimates and Reasons for Lost to Follow-Up Among People Living With HIV on Antiretroviral Therapy in Kisumu County, Kenya. J Acquir Immune Defic Syndr 2022; 90:146-153. [PMID: 35213856 PMCID: PMC9203903 DOI: 10.1097/qai.0000000000002942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Accepted: 02/11/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND A better understanding why people living with HIV (PLHIV) become lost to follow-up (LTFU) and determining who is LTFU in a program setting is needed to attain HIV epidemic control. SETTING This retrospective cross-sectional study used an evidence-sampling approach to select health facilities and LTFU patients from a large HIV program supporting 61 health facilities in Kisumu County, Kenya. METHODS Eligible PLHIV included adults 18 years and older with at least 1 clinic visit between September 1, 2016, and August 31, 2018, and were LTFU (no clinical contact for ≥90 days after their last expected clinic visit). From March to June 2019, demographic and clinical variables were collected from a sample of LTFU patient files at 12 health facilities. Patient care status and retention outcomes were determined through program tracing. RESULTS Of 787 LTFU patients selected and traced, 36% were male, median age was 30.5 years (interquartile range: 24.6-38.0), and 78% had their vital status confirmed with 560 (92%) alive and 52 (8%) deceased. Among 499 (89.0%) with a retention outcome, 233 (46.7%) had stopped care while 266 (53.3%) had self-transferred to another facility. Among those who had stopped care, psychosocial reasons were most common {65.2% [95% confidence interval (CI): 58.9 to 71.1]} followed by structural reasons [29.6% (95% CI: 24.1 to 35.8)] and clinic-based reasons [3.0% (95% CI: 1.4 to 6.2)]. CONCLUSION We found that more than half of patients LTFU were receiving HIV care elsewhere, leading to a higher overall patient retention rate than routinely reported. Similar strategies could be considered to improve the accuracy of reporting retention in HIV care.
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Affiliation(s)
- Benard O Samba
- Center for Microbiology Research, Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Jayne Lewis-Kulzer
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, CA; and
| | - Francesca Odhiambo
- Center for Microbiology Research, Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Eric Juma
- Center for Microbiology Research, Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Edwin Mulwa
- Center for Microbiology Research, Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Julie Kadima
- Center for Microbiology Research, Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Elizabeth A Bukusi
- Center for Microbiology Research, Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Craig R Cohen
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, CA; and
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14
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Pereira CR, Cruz MMD, Cota VL, Almeida BMMD. Linkage strategy and vulnerabilities in the barriers to HIV/AIDS treatment for men who have sex with men. CIENCIA & SAUDE COLETIVA 2022; 27:1535-1546. [PMID: 35475833 DOI: 10.1590/1413-81232022274.08192021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 04/23/2021] [Indexed: 11/22/2022] Open
Abstract
This study aims to analyze the linkage to HIV/AIDS treatment among Men who have Sex with Men (MSM) of the project "A Hora é Agora" in Curitiba, Paraná, Brazil. The concept of vulnerability with its three axes, namely, the individual, social, and programmatic, was the theoretical framework. The barriers from testing up to the onset of the treatment were mapped through linkage registration and minutes from supervisory meetings. In the individual axis, the data revealed that the MSM struggled to address the HIV diagnosis, besides psychological problems that could cause the delay in starting treatment. Considering the social axis, stigma/discrimination was identified in the service at the Basic Health Care Network and within the families, delaying the disclosure of serology. Lastly, in the programmatic axis, the MSM found barriers in accessing the health services due to requests to repeat the HIV test, changing doctors due to poor service, and difficulties in conducting further tests, which adversely reflected on health care. In order to overcome these barriers, it is recommended not only a macro-structural work within this group, but also an investment in the micropolitics, which will enable a real change of attitude, continued care, and a stance related to approaches of care and the defense of life.
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Affiliation(s)
- Carla Rocha Pereira
- Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz. R. Leopoldo Bulhões 1480 Manguinhos, 21041-210. Rio de Janeiro RJ Brasil.
| | - Marly Marques da Cruz
- Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz. R. Leopoldo Bulhões 1480 Manguinhos, 21041-210. Rio de Janeiro RJ Brasil.
| | - Vanda Lúcia Cota
- Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz. R. Leopoldo Bulhões 1480 Manguinhos, 21041-210. Rio de Janeiro RJ Brasil.
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15
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Opio M, Akello F, Twongyeirwe DK, Opio D, Aceng J, Namagga JK, Kabakyenga JK. Perspectives on linkage to care for patients diagnosed with HIV: A qualitative study at a rural health center in South Western Uganda. PLoS One 2022; 17:e0263864. [PMID: 35239667 PMCID: PMC8893616 DOI: 10.1371/journal.pone.0263864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Accepted: 01/29/2022] [Indexed: 11/18/2022] Open
Abstract
Linkage to care for newly diagnosed human immunodeficiency virus (HIV) patients is important to ensure that patients have good access to care. However, there is little information about factors influencing linkage to care for HIV patients. We aimed to identify existing measures in place that promote linkage to care and to explore facilitators and barriers to linkage to care for clients diagnosed with HIV/acquired immune deficiency syndrome at a rural health center in Uganda. This descriptive qualitative study enrolled 33 purposively selected participants who included expert clients, linkage facilitators, heads of families with people living with HIV, and health workers. Data were collected using in-depth interviews that were audio-recorded, transcribed, and translated. The data were manually analyzed to generate themes. The following four themes were generated: 1) availability of services that include counseling, testing, treatment, follow-up, referral, outreach activities, and support systems. 2) Barriers to linkage to care were at the individual, health facility, and community levels. Individual-level barriers were socioeconomic status, high transport costs, fear of adverse drug effects, fear of broken relationships, and denial of positive results or treatment, while health facility barriers were reported to be long waiting time, negative staff attitude, and drug stock outs. Community barriers were mostly due to stigma experienced by HIV clients, resulting in discrimination by community members. 3) Facilitators to linkage to care were positive staff attitudes, access to information, fear of death, and support from others. 4) Suggestions for improving service delivery were shortening waiting time, integrating HIV services, increasing staff numbers, and intensifying outreaches. Our findings highlight the importance of stakeholder involvement in linkage to care. Access and linkage to care are positively and negatively influenced at the individual, community, and health facility levels. However, integration of HIV services and intensifying outreaches are key to improving linkage to care.
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Affiliation(s)
- Mark Opio
- Department of Nursing, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Florence Akello
- Department of Nursing, Mbarara University of Science and Technology, Mbarara, Uganda
| | | | - David Opio
- Department of Nursing, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Juliet Aceng
- Department of Medical Laboratory Science, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Jane Kasozi Namagga
- Department of Nursing, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Jerome Kahuma Kabakyenga
- Maternal Newborn and Child Health Institute, Mbarara University of Science and Technology, Mbarara, Uganda
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16
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Larsen A, Abuna F, Owiti G, Kemunto V, Sila J, Wilson KS, Owens T, Pintye J, Richardson BA, Kinuthia J, John-Stewart G, Kohler P. Improving Quality of PrEP Counseling for Adolescent Girls and Young Women in Kenya With Standardized Patient Actors: A Dose-Response Analysis. J Acquir Immune Defic Syndr 2022; 89:34-39. [PMID: 34560769 PMCID: PMC8665073 DOI: 10.1097/qai.0000000000002814] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 08/27/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Health care worker (HCW) training using standardized patient actors (SPs) is an evidence-based approach for improving patient-provider interactions. We evaluated whether SP training among HCWs in Western Kenya improved the quality of pre-exposure prophylaxis (PrEP) counseling for adolescent girls and young women (AGYW). METHODS We conducted a 2-day SP training intervention among HCWs providing PrEP counseling for AGYW. Six trained SPs role played one encounter each with HCWs following scripts depicting common PrEP-seeking scenarios. SPs used checklists to report and discuss domains of adherence to national PrEP guidelines, communication, and interpersonal skills using validated scales after each encounter. HCWs presented to each case in a random order. Overall and domain-specific mean score percentages were compared between the first and subsequent case encounters using generalized linear models, clustering by HCWs. RESULTS During 564 training cases among 94 HCWs, the overall mean quality of PrEP counseling score was 83.1 (SD: 10.1); scores improved over the course of the 6 encounters (P < 0.001). Compared with the first case encounter, the mean scores for the fourth were significantly higher (79.1 vs. 85.9, P < 0.001). The mean scores plateaued from the fourth to the sixth case (85.2). Although HCWs demonstrated high baseline communication (95.3) and interpersonal skills (83.7), adherence to PrEP guidelines at baseline was suboptimal (57.6). By the fourth case, scores increased significantly (P < 0.001) for all domains. CONCLUSIONS SP training improved PrEP counseling overall and in domains of interpersonal skills, use of guidelines, and communication with AGYW and could be useful in efforts to improve the quality of PrEP counseling for AGYW.
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Affiliation(s)
- Anna Larsen
- Departments of Global Health
- Epidemiology, University of Washington, Seattle, WA
| | - Felix Abuna
- Department of Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - George Owiti
- Department of Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Valarie Kemunto
- Department of Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Joseph Sila
- Department of Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Kate S Wilson
- Policy Development & Evaluation Unit, Public Health Seattle/King County, Seattle, WA
| | - Tamara Owens
- Clinical Skills & Simulation Centers, Howard University, Washington, DC
| | - Jillian Pintye
- Departments of Global Health
- Departments of Biobehavioral Nursing and Health Informatics
| | | | - John Kinuthia
- Departments of Global Health
- Department of Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Grace John-Stewart
- Departments of Global Health
- Epidemiology, University of Washington, Seattle, WA
- Medicine
- Pediatrics; and
| | - Pamela Kohler
- Child, Family, and Population Health Nursing, University of Washington, Seattle, WA
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17
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Mbatha TL, Dube A. HIV Positive Pregnant Mothers' Perceptions and Experiences Regarding the Prevention of Mother-to-Child Transmission, Option B+ Program. J Patient Exp 2021; 8:23743735211065272. [PMID: 34901413 PMCID: PMC8655469 DOI: 10.1177/23743735211065272] [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] [Indexed: 11/25/2022] Open
Abstract
Background: eSwatini is a small population-sized sub-Sahara African country characterized by its highest human immunodeficiency virus (HIV) prevalence globally. The prevalence of HIV among pregnant women is above 40%. In the past decade, the Government of eSwatini has demonstrated a high level of commitment to virally suppress HIV spread among its population. This study explored the perceptions and experiences of HIV-positive pregnant mothers regarding the prevention of mother-to-child transmission (PMTCT) Option B+ program in order to discuss and address the gaps in the health system. Methods: Qualitative, exploratory, and descriptive research design was used. Data was collected through in-depth interviews and field notes. Data was gathered from all cases of HIV-positive pregnant mothers enrolled at a Public Health Unit. Results: Seventeen pregnant women aged between 18 and 40 years participated. Findings revealed that the Option B+ program was positively perceived as preventing HIV from mother-to-child. It boosts the immune system, deters opportunistic infections, and prolongs life. Knowledge and understanding of the program were displayed despite challenges such as discrimination and no support from families. Conclusion: PMTCT Option B+ intervention was found to be effective in reducing mother-to-child transmission of HIV. Gaps between women and men about HIV and antiretroviral therapy need to be addressed through target messaging and stigmatization discussions so that men are encouraged to disclose their HIV status. Improving access to antiretroviral and retention of women on treatment can further reduce vertical HIV infection transmission.
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Affiliation(s)
- Trusty L Mbatha
- Department of Nursing Sciences, Southern Africa Nazarene University, Manzini, Swaziland
| | - Adiele Dube
- Department of Nursing Sciences, Southern Africa Nazarene University, Manzini, Swaziland
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18
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Wachira J, Mwangi A, Chemutai D, Nyambura M, Genberg B, Wilson IB. Higher Clinician-Patient Communication Is Associated With Greater Satisfaction With HIV Care. J Int Assoc Provid AIDS Care 2021; 20:23259582211054935. [PMID: 34787014 PMCID: PMC8606924 DOI: 10.1177/23259582211054935] [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] [Indexed: 11/17/2022] Open
Abstract
Provider-patient communication (PPC) skills are key in promoting patient satisfaction. Our study examined the relationship between clinician PPC skills and patient satisfaction with care among virally unsuppressed adult HIV patients in Busia County, Kenya. This cross-sectional study was conducted among 360 HIV patients on first line antiretroviral regimen and having a recent viral load ≥400 copies HIV RNA/ml. We conducted logistic regression analysis. The mean age of participants was 48.2 years [standard deviation (SD): 12.05]. Overall, the mean score on clinician PPC skills was 33.3 (SD: 9.0). A high proportion (85%) of participants reported satisfaction with the HIV care services. After adjusting for covariates, the odds of being satisfied with care increased by 19% (adjusted odds ratio: 1.19, 95% CI: 1.11-1.30) for every one unit increase in the clinician PPC skills score. Promoting good PPC skills may be key to improving patient satisfaction with HIV care.
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Affiliation(s)
- Juddy Wachira
- School of Medicine, College of Health Sciences, 130188Moi University Eldoret, Kenya.,School of Literature, Language and Media, 208666University of Witwatersrand, Johannesburg, South Africa
| | - Ann Mwangi
- Institute of Biomedical Informatics, College of Health Sciences, 107853Moi University, Eldoret, Kenya, USA
| | - Diana Chemutai
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | - Monica Nyambura
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | - Becky Genberg
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Ira B Wilson
- School of Public Health, Brown University, Providence, RI, USA
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19
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Wekesa P, McLigeyo A, Owuor K, Mwangi J, Isavwa L, Katana A. Temporal trends in pre-ART patient characteristics and outcomes before the test and treat era in Central Kenya. BMC Infect Dis 2021; 21:1007. [PMID: 34565337 PMCID: PMC8474838 DOI: 10.1186/s12879-021-06706-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 09/16/2021] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Retention of patients who did not initiate antiretroviral therapy (ART) has been persistently low compared to those who initiated ART. Understanding the temporal trends in clinical outcomes prior to ART initiation may inform interventions targeting patients who do not initiate ART immediately after diagnosis. METHODS A retrospective cohort analysis of known HIV-infected patients who did not initiate ART from healthcare facilities in Central Kenya was done to investigate temporal trends in characteristics, retention, and mortality outcomes. The data were sourced from the Comprehensive Care Clinic Patient Application Database (CPAD) and IQ care electronic patient-level databases for those enrolled between 2004 and 2014. RESULTS A total of 13,779 HIV-infected patients were assessed, of whom 30.7% were men.There were statisitically significant differences in temporal trends relating to marital status, WHO clinical stage, and tuberculosis (TB) status from 2004 to 2014. The proportion of widowed patients decreased from 9.1 to 6.0%. By WHO clinical stage at enrollment in program, those in WHO stage I increased over time from 8.7 to 43.1%, while those in WHO stage III and IV reduced from 28.5 to 10.8% and 4.0 to 1.1% respectively. Those on TB treatment during their last known visit reduced from 8.3 to 3.9% while those with no TB signs increased from 58.5 to 86.8%. Trends in 6 and 12 month retention in the program, loss to follow-up (LTFU) and mortality were statistically significant. At 6 months, program retention ranged between 36.0% in 2004 to a high of 54.1% in 2013. LTFU at 6 months remained around 50.0% for most of the cohorts, while mortality at 6 months was 7.5% in 2004 but reduced to 3.8% in 2014. At 12 months, LTFU was above 50.0% across all the cohorts while mortality rate reached 3.9% in 2014. CONCLUSION Trends in pre ART enrollment suggested higher enrollment among patients who were women and at earlier WHO clinical stages. Retention and mortality outcomes at 6 and 12 months generally improved over the 11 year follow-up period, though dipped as enrollment in asymptomatic disease stage increased.
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Affiliation(s)
- P Wekesa
- Centre for Health Solutions - Kenya, Nairobi, Kenya.
| | - A McLigeyo
- Centre for Health Solutions - Kenya, Nairobi, Kenya.
| | - K Owuor
- Centre for Health Solutions - Kenya, Nairobi, Kenya
| | - J Mwangi
- Division of Global HIV & TB, Centers for Disease Control and Prevention (CDC), Nairobi, Kenya
| | - L Isavwa
- Centre for Health Solutions - Kenya, Nairobi, Kenya
| | - A Katana
- Division of Global HIV & TB, Centers for Disease Control and Prevention (CDC), Nairobi, Kenya
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Mnyaka OR, Mabunda SA, Chitha WW, Nomatshila SC, Ntlongweni X. Barriers to the Implementation of the HIV Universal Test and Treat Strategy in Selected Primary Care Facilities in South Africa's Eastern Cape Province. J Prim Care Community Health 2021; 12:21501327211028706. [PMID: 34189991 PMCID: PMC8252362 DOI: 10.1177/21501327211028706] [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] [Indexed: 11/17/2022] Open
Abstract
Background: The South African government implemented the Universal Test and Treat (UTT) approach to treating HIV in the second half of 2016. As part of a contribution to the successful implementation of UTT, this study looked at barriers to implementation of UTT emanating from weaknesses of the health system in 2 Community Health Centers in South Africa’s Eastern Cape Province. Methods: This was a quantitative cross-sectional design which had both descriptive and analytical components. Convenience sampling was used to select and recruit 2 primary care facilities and 30 nurses. Self-administered questionnaires were used to solicit data from facility managers and nurses. In addition, a record review was used to access 6 months’ data for the period 1 October 2017 to 31 March 2018. Data were analyzed using Stata 14.1. Categorical data were presented using frequency and contingency tables. The 95% confidence interval (95% CI) is used for the precision of estimates and the P-value of statistical significance is P < .05. Results: Facilities were found to have poor leadership and governance; human resource challenges that include shortages, lack of skills and lack of developmental support; poorly resourced service delivery platforms and poor information management. Of the three 90-90-90 targets, health facilities only satisfactorily achieved the second 90 of initiating all who test positive for HIV within a week (93.1% or n = 288/307). Conclusions: This study has been able to identify potential barriers to the implementation of the UTT strategy at the selected facilities including the lack of structured programs in place to monitor performance of healthcare staff, knowledge gaps, and a lack of good clinical governance practices as evidenced by the lack of customized protocols and Standard Operating Procedures.
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Affiliation(s)
- Onke R Mnyaka
- University of the Witwatersrand, Johannesburg, South Africa
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Genberg BL, Wachira J, Steingrimsson JA, Pastakia S, Tran DNT, Said JA, Braitstein P, Hogan JW, Vedanthan R, Goodrich S, Kafu C, Wilson-Barthes M, Galárraga O. Integrated community-based HIV and non-communicable disease care within microfinance groups in Kenya: study protocol for the Harambee cluster randomised trial. BMJ Open 2021; 11:e042662. [PMID: 34006540 PMCID: PMC8137246 DOI: 10.1136/bmjopen-2020-042662] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
INTRODUCTION In Kenya, distance to health facilities, inefficient vertical care delivery and limited financial means are barriers to retention in HIV care. Furthermore, the increasing burden of non-communicable diseases (NCDs) among people living with HIV complicates chronic disease treatment and strains traditional care delivery models. Potential strategies for improving HIV/NCD treatment outcomes are differentiated care, community-based care and microfinance (MF). METHODS AND ANALYSIS We will use a cluster randomised trial to evaluate integrated community-based (ICB) care incorporated into MF groups in medium and high HIV prevalence areas in western Kenya. We will conduct baseline assessments with n=900 HIV positive members of 40 existing MF groups. Group clusters will be randomised to receive either (1) ICB or (2) standard of care (SOC). The ICB intervention will include: (1) clinical care visits during MF group meetings inclusive of medical consultations, NCD management, distribution of antiretroviral therapy (ART) and NCD medications, and point-of-care laboratory testing; (2) peer support for ART adherence and (3) facility referrals as needed. MF groups randomised to SOC will receive regularly scheduled care at a health facility. Findings from the two trial arms will be compared with follow-up data from n=300 matched controls. The primary outcome will be VS at 18 months. Secondary outcomes will be retention in care, absolute mean change in systolic blood pressure and absolute mean change in HbA1c level at 18 months. We will use mediation analysis to evaluate mechanisms through which MF and ICB care impact outcomes and analyse incremental cost-effectiveness of the intervention in terms of cost per HIV suppressed person-time, cost per patient retained in care and cost per disability-adjusted life-year saved. ETHICS AND DISSEMINATION The Moi University Institutional Research and Ethics Committee approved this study (IREC#0003054). We will share data via the Brown University Digital Repository and disseminate findings via publication. TRIAL REGISTRATION NUMBER NCT04417127.
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Affiliation(s)
- Becky L Genberg
- Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Juddy Wachira
- Behavioral Sciences, Moi University College of Health Sciences, School of Medicine, Eldoret, Kenya
| | - Jon A Steingrimsson
- Biostatistics, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Sonak Pastakia
- Center for Health Equity and Innovation, Purdue University College of Pharmacy, Indianapolis, Indiana, USA
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Dan N Tina Tran
- Center for Health Equity and Innovation, Purdue University College of Pharmacy, Indianapolis, Indiana, USA
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Jamil AbdulKadir Said
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
- Internal Medicine, Moi University School of Medicine, Eldoret, Kenya
| | - Paula Braitstein
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
- Epidemiology, University of Toronto Dalla Lana School of Public Health, Toronto, Ontario, Canada
| | - Joseph W Hogan
- Biostatistics, Brown University School of Public Health, Providence, Rhode Island, USA
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Rajesh Vedanthan
- Global Health, New York University Grossman School of Medicine, New York, New York, USA
| | - Suzanne Goodrich
- Division of Infectious Diseases, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Catherine Kafu
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Marta Wilson-Barthes
- Epidemiology, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Omar Galárraga
- Health Services, Policy and Practice, Brown University School of Public Health, 121 South Main St. Box G-S121-2 Providence, Rhode Island, USA
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Olwanda EE, Kahn JG, Choi Y, Islam JY, Huchko M. Comparison of the costs of HPV testing through community health campaigns versus home-based testing in rural Western Kenya: a microcosting study. BMJ Open 2020; 10:e033979. [PMID: 33109637 PMCID: PMC7592277 DOI: 10.1136/bmjopen-2019-033979] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 07/29/2020] [Accepted: 09/21/2020] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To estimate the cost of human papillomavirus (HPV)-based screening through community health campaigns (CHCs) and home-based testing. SETTING CHCs and home-based testing in six communities in rural Western Kenya. PARTICIPANTS CHCs and home-based screening reached 2297 and 1002 women aged 25-65 years, respectively. OUTCOME MEASURES Outcome measures were overall cost per woman screened achieved through the CHCs and home-based testing and the cost per woman for each activity comprising the screening intervention. RESULTS The mean cost per woman screened through CHCs and home-based testing were similar, at $37.7 (range $26.4-$52.0) and $37.1 (range $27.6-$54.0), respectively. For CHCs, personnel represented 49% of overall cost, supplies 25%, services 5% and capital goods 23%. For home-based testing, these were: personnel 73%, supplies 25%, services 1% and capital goods 2%. A greater number of participants was associated with a lower cost per participant. CONCLUSIONS The mean cost per woman screened is comparable for CHC and home-based testing, with differences in type of input. The CHCs generally reached more eligible women in the six communities, whereas home-based strategies more efficiently reached populations with low screening rates. TRIAL REGISTRATION NUMBER NCT02124252.
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Affiliation(s)
| | - James G Kahn
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, CA, USA
| | - Yujung Choi
- Duke Global Health Institute, Duke University, Durham, NC, USA
- Duke University, Department of Obstetrics and Gynecology, Durham, NC, USA
| | - Jessica Yasmine Islam
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Megan Huchko
- Duke Global Health Institute, Duke University, Durham, NC, USA
- Duke University, Department of Obstetrics and Gynecology, Durham, NC, USA
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Larsen A, Wilson KS, Kinuthia J, John-Stewart G, Richardson BA, Pintye J, Abuna F, Lagat H, Owens T, Kohler P. Standardised patient encounters to improve quality of counselling for pre-exposure prophylaxis (PrEP) in adolescent girls and young women (AGYW) in Kenya: study protocol of a cluster randomised controlled trial. BMJ Open 2020; 10:e035689. [PMID: 32565464 PMCID: PMC7311012 DOI: 10.1136/bmjopen-2019-035689] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 02/03/2020] [Accepted: 05/26/2020] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION Adolescent girls and young women (AGYW) in sub-Saharan Africa are at high risk of HIV acquisition. Pre-exposure prophylaxis (PrEP) demonstration projects observe that AGYW uptake and adherence to PrEP during risk periods is suboptimal. Judgemental interactions with healthcare workers (HCW) and inadequate counselling can be barriers to PrEP use among AGYW. Improving HCW competency and communication to support PrEP delivery to AGYW requires new strategies. METHODS AND ANALYSIS PrEP Implementation for Young Women and Adolescents Program-standardised patient (PrIYA-SP) is a cluster randomised trial of a standardised patient actor (SP) training intervention designed to improve HCW adherence to PrEP guidelines and communication skills. We purposively selected 24 clinics offering PrEP services under fully programmatic conditions in Kisumu County, Kenya. At baseline, unannounced SP 'mystery shoppers' present to clinics portraying AGYW in common PrEP scenarios for a cross-sectional assessment of PrEP delivery. Twelve facilities will be randomised to receive a 2-day training intervention, consisting of lectures, role-playing with SPs and group debriefing. Unannounced SPs will repeat the assessment in all 24 sites following the intervention. The primary outcome is quality of PrEP counselling, including adherence to national guidelines and communication skills, scored on a checklist by SPs blinded to intervention assignment. An intention-to-treat (ITT) analysis will evaluate whether the intervention resulted in higher scores within intervention compared with control facilities, adjusted for baseline SP scores and accounting for clustering by facility. We hypothesise that the intervention will improve quality of PrEP counselling compared with standard of care. Results from this study will inform guidelines for PrEP delivery to AGYW in low-resource settings and offer a potentially scalable strategy to improve service delivery for this high-risk group. ETHICS AND DISSEMINATION The protocol was approved by institutional review boards at Kenyatta National Hospital and University of Washington. An external advisory committee monitors social harms. Results will be disseminated through peer-reviewed journals and presentations. TRIAL REGISTRATION NUMBER NCT03875950.
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Affiliation(s)
- Anna Larsen
- Department of Global Health, University of Washington, Seattle, Washington, USA
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | - Kate S Wilson
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - John Kinuthia
- Department of Global Health, University of Washington, Seattle, Washington, USA
- Research and Programs, Kenyatta National Hospital/University of Nairobi, Nairobi, Kenya
| | - G John-Stewart
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
- Department of Medicine, University of Washington, Seattle, Washington, USA
- Department of Pediatrics, University of Washington, Seattle, WA, United States
| | - B A Richardson
- Department of Biostatistics, University of Washington, Seattle, WA, United States
| | - Jillian Pintye
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Felix Abuna
- Research and Programs, Kenyatta National Hospital/University of Nairobi, Nairobi, Kenya
| | - Harison Lagat
- Research and Programs, Kenyatta National Hospital/University of Nairobi, Nairobi, Kenya
| | - Tamara Owens
- Health Sciences Simulation & Clinical Skills Center, Howard University, Seattle, Washington, DC, USA
| | - Pamela Kohler
- Department of Child, Family, and Population Health Nursing, University of Washington, Seattle, Washington, USA
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Meka AFZ, Billong SC, Diallo I, Tiemtore OW, Bongwong B, Nguefack-Tsague G. Challenges and barriers to HIV service uptake and delivery along the HIV care cascade in Cameroon. Pan Afr Med J 2020; 36:37. [PMID: 32774613 PMCID: PMC7392033 DOI: 10.11604/pamj.2020.36.37.19046] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Accepted: 01/19/2020] [Indexed: 11/11/2022] Open
Abstract
Introduction The year 2017 marked a transition period with the end of the implementation of Cameroon´s 2014-2017 HIV/AIDS National Strategic Plan (NSP) and the development of the 2018-2022 NSP. We assessed barriers and challenges to service delivery and uptake along the HIV care cascade in Cameroon to inform decision making within the framework of the new NSP, to achieve the UNAIDS 90-90-90 target. Methods We conducted a cross sectional descriptive study nationwide, enrolling HIV infected patients and staff. Data were collected on sociodemographic characteristics, HIV testing, antiretroviral therapy and viral load testing delivery and uptake and factors that limit their access. Results A total of 137 staff and 642 people living with HIV (PLHIV) were interviewed. Of 642 PLHIV with known status, 339 (53%) repeated their HIV test at least once, with range: 1-10 and median: 2 (IQR: 1-3). Having attained secondary level of education (OR: 2.07, 95% CI: 1.04-4.14; P=0.04) or more (OR: 2.91, 95% CI: 1.16-7.28; P=0.02) were significantly associated with repeat testing. Psychological (refusal of service uptake and existence of HIV), community-level (stigmatization and fear of confidentiality breach) and commodity stock-outs “HIV test kits (21%), antiretrovirals (ARVs) (71.4%), viral load testing reagents (100%)” are the major barriers to service delivery and uptake along the cascade. Conclusion We identified individual, community-level, socio-economic and health care system related barriers which constitute persistent bottlenecks in HIV service delivery and uptake and a high rate of repeat testing by PLHIV with known status. Addressing all these accordingly can help the country achieve the UNAIDS 90-90-90 target.
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Affiliation(s)
| | - Serge Clotaire Billong
- National Aids Control Committee, Ministry of Public Health, Yaounde, Cameroon.,Faculty of Medicine and Biomedical Sciences, University of Yaounde, Yaounde, Cameroon
| | - Ismael Diallo
- Centre Hospitalier Universitaire Yalgado Ouedraogo, Ouagadougou, Burkina-Faso.,Initiatives Conseil International-Santé (ICI-Santé), Ouagadougou, Burkina-Faso
| | | | - Brian Bongwong
- Faculty of Medicine and Biomedical Sciences, University of Yaounde, Yaounde, Cameroon
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Genberg B, Wachira J, Kafu C, Wilson I, Koech B, Kamene R, Akinyi J, Knight J, Braitstein P, Ware N. Health System Factors Constrain HIV Care Providers in Delivering High-Quality Care: Perceptions from a Qualitative Study of Providers in Western Kenya. J Int Assoc Provid AIDS Care 2020; 18:2325958218823285. [PMID: 30798666 PMCID: PMC6503317 DOI: 10.1177/2325958218823285] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
The burden on health systems due to increased volume of patients with HIV continues to rapidly increase. The goal of this study was to examine the experiences of HIV care providers in a high patient volume HIV treatment and care program in eastern Africa. Sixty care providers within the Academic Model Providing Access to Healthcare program in western Kenya were recruited into this qualitative study. We conducted in-depth interviews focused on providers’ perspectives on health system factors that impact patient engagement in HIV care. Results from thematic analysis demonstrated that providers perceive a work environment that constrained their ability to deliver high-quality HIV care and encouraged negative patient–provider relationships. Providers described their roles as high strain, low control, and low support. Health system strengthening must include efforts to improve the working environment and easing burden of care providers tasked with delivering antiretroviral therapy to increasing numbers of patients in resource-constrained settings.
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Affiliation(s)
- Becky Genberg
- 1 Department of Health Services, Policy & Practice, Brown University, Providence, RI, USA.,2 Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Juddy Wachira
- 3 Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya.,4 Department of Behavioral Science, Moi University, College of Health Sciences, School of Medicine, Eldoret, Kenya
| | - Catherine Kafu
- 3 Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Ira Wilson
- 1 Department of Health Services, Policy & Practice, Brown University, Providence, RI, USA
| | - Beatrice Koech
- 3 Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Regina Kamene
- 3 Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Jacqueline Akinyi
- 3 Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Jennifer Knight
- 1 Department of Health Services, Policy & Practice, Brown University, Providence, RI, USA
| | - Paula Braitstein
- 3 Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya.,4 Department of Behavioral Science, Moi University, College of Health Sciences, School of Medicine, Eldoret, Kenya.,5 Department of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,6 Fairbanks School of Public Health, Indiana University, Indianapolis, IN, USA.,7 Regenstrief Institute, Indianapolis, IN, USA
| | - Norma Ware
- 8 Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA.,9 Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
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Harklerode R, Todd J, de Wit M, Beard J, Urassa M, Machemba R, Maduhu B, Hargreaves J, Somi G, Rice B. Characterizing a Leak in the HIV Care Cascade: Assessing Linkage Between HIV Testing and Care in Tanzania. Front Public Health 2020; 7:406. [PMID: 32083047 PMCID: PMC7002436 DOI: 10.3389/fpubh.2019.00406] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 12/19/2019] [Indexed: 11/24/2022] Open
Abstract
Background: In Tanzania, HIV testing data are reported aggregately for national surveillance, making it difficult to accurately measure the extent to which newly diagnosed persons are entering care, which is a critical step of the HIV care cascade. We assess, at the individual level, linkage of newly diagnosed persons to HIV care. Methods: An expanded two-part referral form was developed to include additional variables and unique identifiers. The expanded form contained a corresponding number for matching the two-parts between testing and care. Data were prospectively collected at 16 health facilities in the Magu District of Tanzania. Results: The records of 1,275 unique people testing HIV positive were identified and included in our analysis. Of these, 1,200 (94.1%) responded on previous testing history, with 184 (15.3%) testing twice or more during the pilot, or having had a previous HIV positive test. Three-quarters (932; 73.1%) of persons were linked to care during the pilot timeframe. Health service provision in the facility carrying out the HIV test was the most important factor for linkage to care; poor linkage occurred in facilities where HIV care was not immediately available. Conclusions: It is critical for persons newly diagnosed with HIV to be linked to care in a timely manner to maximize treatment effectiveness. Our findings show it is feasible to measure linkage to care using routinely collected data arising from an amended national HIV referral form. Our results illustrate the importance of utilizing individual-level data for measuring linkage to care, as repeat testing is common.
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Affiliation(s)
- Richelle Harklerode
- Institute for Global Health Sciences, University of California, San Francisco, San Francisco, CA, United States
| | - Jim Todd
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Mariken de Wit
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - James Beard
- National Institute for Medical Research, Mwanza, Tanzania
| | - Mark Urassa
- National Institute for Medical Research, Mwanza, Tanzania
| | | | | | - James Hargreaves
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Geoffrey Somi
- Ministry of Health, Community Development, Gender, Elderly and Children, Dar es Salaam, Tanzania
| | - Brian Rice
- London School of Hygiene and Tropical Medicine, London, United Kingdom
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Karman E, Wilson KS, Mugo C, Slyker JA, Guthrie BL, Bukusi D, Inwani I, John-Stewart GC, Wamalwa D, Kohler PK. Training Exposure and Self-Rated Competence among HIV Care Providers Working with Adolescents in Kenya. J Int Assoc Provid AIDS Care 2020; 19:2325958220935264. [PMID: 32588709 PMCID: PMC7322818 DOI: 10.1177/2325958220935264] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 05/20/2020] [Accepted: 05/26/2020] [Indexed: 11/17/2022] Open
Abstract
Lack of health care worker (HCW) training is a barrier to implementing youth-friendly services. We examined training coverage and self-reported competence, defined as knowledge, abilities, and attitudes, of HCWs caring for adolescents living with HIV (ALWH) in Kenya. Surveys were conducted with 24 managers and 142 HCWs. Competence measures were guided by expert input and Kalamazoo II Consensus items. Health care workers had a median of 3 (interquartile range [IQR]: 1-6) years of experience working with ALWH, and 40.1% reported exposure to any ALWH training. Median overall competence was 78.1% (IQR: 68.8-84.4). In multivariable linear regression analyses, more years caring for ALWH and any prior training in adolescent HIV care were associated with significantly higher self-rated competence. Training coverage for adolescent HIV care remains suboptimal. Targeting HCWs with less work experience and training exposure may be a useful and efficient approach to improve quality of youth-friendly HIV services.
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Affiliation(s)
- Elizabeth Karman
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Kate S. Wilson
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Cyrus Mugo
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Paediatrics and Child Health/Kenyatta National Hospital, University of Nairobi, Kenya
| | - Jennifer A. Slyker
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Brandon L. Guthrie
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - David Bukusi
- VCT and HIV Prevention Unit/Youth Centre, Kenyatta National Hospital, Nairobi, Kenya
| | - Irene Inwani
- Department of Paediatrics and Child Health/Kenyatta National Hospital, University of Nairobi, Kenya
| | - Grace C. John-Stewart
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Department of Medicine, University of Washington, Seattle, WA, USA
- Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Dalton Wamalwa
- Department of Paediatrics and Child Health/Kenyatta National Hospital, University of Nairobi, Kenya
| | - Pamela K. Kohler
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Child, Family, and Population Health Nursing, University of Washington, Seattle, WA, USA
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Genberg BL, Hogan JW, Xu Y, Nyambura M, Tarus C, Rotich E, Kafu C, Wachira J, Goodrich S, Braitstein P. Population-based estimates of engagement in HIV care and mortality using double-sampling methods following home-based counseling and testing in western Kenya. PLoS One 2019; 14:e0223187. [PMID: 31577834 PMCID: PMC6774575 DOI: 10.1371/journal.pone.0223187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 09/16/2019] [Indexed: 11/18/2022] Open
Abstract
Introduction Data on engagement in HIV care from population-based samples in sub-Saharan Africa are limited. The objective of this study was to use double-sampling methods to estimate linkage to HIV care, ART initiation, and mortality among all adults diagnosed with HIV by a comprehensive home-based counseling and testing (HBCT) program in western Kenya. Methods HBCT was conducted door-to-door from December 2009 to April 2011 in three sub-counties of western Kenya by AMPATH (Academic Model Providing Access to Healthcare). For those identified as HIV-positive, data were merged with electronic medical records to determine engagement with HIV care. A randomly-drawn follow-up sample of 120 adults identified via HBCT who had not linked to care as of June 2015 in Bunyala sub-county were visited by trained fieldworkers to ascertain HIV care engagement and vital status. Double-sampled data were used to generate, via multinomial regression, predicted probabilities of engagement in care and mortality among those whose status could not be ascertained by matching with the electronic medical records in the three catchments. Results Incorporating information from the double-sampling yielded estimates of prospective linkage to HIV care that ranged from 40–45%. Mortality estimates of those who did not engage in care following HBCT ranged from 12–16%. Among those who linked to care following HBCT, between 72–81% initiated ART. Discussion In settings without universal national identifiers, rates of linkage to care from community-based programs may be subject to substantial underestimation. Follow-up samples of those with missing information can be used to partially correct this bias, as has been demonstrated previously for mortality among those who were lost-to-care programs. There is a need for harmonized data systems across health systems and programs.
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Affiliation(s)
- Becky L. Genberg
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Brown University, Providence, Rhode Island, United States of America
| | - Joseph W. Hogan
- Department of Biostatistics, Brown University School of Public Health, Brown University, Providence, Rhode Island, United States of America
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Yizhen Xu
- Department of Biostatistics, Brown University School of Public Health, Brown University, Providence, Rhode Island, United States of America
| | - Monicah Nyambura
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Caren Tarus
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Elyne Rotich
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Catherine Kafu
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Juddy Wachira
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
- College of Health Sciences, School of Medicine, Moi University, Eldoret, Kenya
| | - Suzanne Goodrich
- Division of Infectious Diseases, School of Medicine, Indiana University, Indianapolis, Indiana, United States of America
| | - Paula Braitstein
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
- College of Health Sciences, School of Medicine, Moi University, Eldoret, Kenya
- Epidemiology Division, Office of Global Public Health Education & Training, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- * E-mail:
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Emerson C, Ndakidemi E, Ngowi B, Medley A, Ng'eno B, Godwin M, Ntinginya N, Carpenter D, Kohi W, Modi S. Caregiver perspectives on TB case-finding and HIV clinical services for children diagnosed with TB in Tanzania. AIDS Care 2019; 32:495-499. [PMID: 31550905 DOI: 10.1080/09540121.2019.1668520] [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: 10/25/2022]
Abstract
Caregivers of children with tuberculosis (TB) and HIV play a critical role in seeking healthcare for their children. To assess the perspectives of caregivers of pediatric TB patients, we conducted 76 in-depth interviews at 10 TB clinics in 5 districts of Tanzania in March 2016. We assessed how the child received their TB diagnosis, the decision-making process around testing the child for HIV, and the process of linking the child to HIV treatment in the event of an HIV diagnosis. Caregivers suspected TB due to cases in their family, or the child being ill and not improving. Most caregivers noted delays before confirmation of a TB diagnosis and having to visit multiple facilities before a diagnosis. Once diagnosed, some caregivers reported challenges administering TB medications due to lack of pediatric formulations. Reasons for accepting HIV testing included recurrent illness and HIV symptoms, history of HIV in the family, and recommendation of the clinical provider. Caregivers described a relatively seamless process for linking their child to HIV treatment, highlighting the success of TB/HIV integration efforts. The multiple clinic visits required prior to TB diagnosis suggests the need for additional training and sensitization of healthcare workers and better TB diagnostic tools.
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Affiliation(s)
- Courtney Emerson
- Division of Global HIV/TB, Center for Global Health, Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA
| | | | - Bernard Ngowi
- National Institute for Medical Research Muhimbili Research Centre, Dar es Salaam, Tanzania
| | - Amy Medley
- Division of Global HIV/TB, Center for Global Health, Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA
| | - Bernadette Ng'eno
- Division of Global HIV/TB, Center for Global Health, Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA
| | | | - Nyanda Ntinginya
- Tanzania Ministry of Health, Community Development, Gender, Elderly and Children, Dar es Salaam, Tanzania
| | - Deborah Carpenter
- Tanzania Ministry of Health, Community Development, Gender, Elderly and Children, Dar es Salaam, Tanzania
| | - Wanze Kohi
- Tanzania Ministry of Health, Community Development, Gender, Elderly and Children, Dar es Salaam, Tanzania
| | - Surbhi Modi
- Division of Global HIV/TB, Center for Global Health, Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA
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Ngandu NK, Jackson D, Lombard C, Nsibande DF, Dinh TH, Magasana V, Mogashoa M, Goga AE. Factors associated with non-attendance at scheduled infant follow-up visits in an observational cohort of HIV-exposed infants in South Africa, 2012-2014. BMC Infect Dis 2019; 19:788. [PMID: 31526372 PMCID: PMC6745773 DOI: 10.1186/s12879-019-4340-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background Since 2001 the South African guidelines to improve child health and prevent vertical HIV transmission recommended frequent infant follow-up with HIV testing at 18 months postpartum. We sought to understand non-attendance at scheduled follow-up study visits up to 18 months, and for the 18-month infant HIV test amongst a nationally representative sample of HIV exposed uninfected (HEU) infants from a high HIV-prevalence African setting. Methods Secondary analysis of data drawn from a nationally representative observational cohort study (conducted during October 2012 to September 2014) of HEU infants and their primary caregivers was undertaken. Participants were eligible (N = 2650) if they were 4–8 weeks old and HEU at enrolment. All enrolled infants were followed up every 3 months up to 18 months. Each follow-up visit was scheduled to coincide with each child’s routine health visit, where possible. The denominator at each time point comprised HEU infants who were alive and HIV-free at the previous visit. We assessed baseline maternal and early HIV care characteristics associated with the frequency of ‘Missed visits’ (MV-frequency), using a negative binomial regression model adjusting for the follow-up time in the study, and associated with missed visits at 18 months (18-month MV) using a logistic regression model. Results The proportion of eligible infants with MV was lowest at 3 months (32.7%) and 18 months (31.0%) and highest at 12 months (37.6%). HIV-positive mothers not on triple antiretroviral therapy (ART) by 6-weeks postpartum had a significantly increased occurrence rate of ‘MV-frequency’ (adjusted incidence rate ratio, 1.2 (95% confidence interval (CI), 1.1–1.4), p < 0.0001). Compared to those mothers with ART, these mothers also increased the risk of ‘18-month-MV’ (adjusted odds ratio, 1.3 (CI, 1.1–1.6), p = 0.006). Unknown infant nevirapine-intake status increased the rate of ‘MV-frequency’ (p = 0.02). Mothers > 24 years had a significantly reduced rate of ‘MV-frequency’ (p ≤ 0.01) and risk of ‘18-month-MV’ (p < 0.01) compared to younger women. Shorter travel time to health facility lowered the occurrence of ‘MV-frequency’ (p ≤ 0.004). Conclusion Late initiation of maternal ART and infant prophylaxis under the Option- A policy and extended travel time to clinics (measured at 6 weeks postpartum), contributed to higher postnatal MV rates. Mothers older than 24 years had lower MV rates. Targeted interventions may be needed during the current PMTCT Option B+ (lifelong ART to pregnant and lactating women at HIV diagnosis) to circumvent these risk factors and reduce missed visits during HIV-care. Electronic supplementary material The online version of this article (10.1186/s12879-019-4340-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nobubelo Kwanele Ngandu
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa.
| | - Debra Jackson
- UNICEF, New York, NY, USA.,School of Public Health, University of the Western Cape, Cape Town, South Africa
| | - Carl Lombard
- Biostatistics Unit, South African Medical Research Council, Cape Town, South Africa.,School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Duduzile Faith Nsibande
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Thu-Ha Dinh
- Division of Global HIV and Tuberculosis, Centers for Disease Control and Prevention, Center for Global Health, Atlanta, GA, USA
| | - Vuyolwethu Magasana
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Mary Mogashoa
- US Center for Disease Control and Prevention, Pretoria, South Africa
| | - Ameena Ebrahim Goga
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa.,Department of Paediatrics, University of Pretoria, Pretoria, South Africa
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Mateo-Urdiales A, Johnson S, Smith R, Nachega JB, Eshun-Wilson I. Rapid initiation of antiretroviral therapy for people living with HIV. Cochrane Database Syst Rev 2019; 6:CD012962. [PMID: 31206168 PMCID: PMC6575156 DOI: 10.1002/14651858.cd012962.pub2] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Despite antiretroviral therapy (ART) being widely available, HIV continues to cause substantial illness and premature death in low-and-middle-income countries. High rates of loss to follow-up after HIV diagnosis can delay people starting ART. Starting ART within seven days of HIV diagnosis (rapid ART initiation) could reduce loss to follow-up, improve virological suppression rates, and reduce mortality. OBJECTIVES To assess the effects of interventions for rapid initiation of ART (defined as offering ART within seven days of HIV diagnosis) on treatment outcomes and mortality in people living with HIV. We also aimed to describe the characteristics of rapid ART interventions used in the included studies. SEARCH METHODS We searched CENTRAL, the Cochrane Database of Systematic Reviews, MEDLINE, Embase, and four other databases up to 14 August 2018. There was no restriction on date, language, or publication status. We also searched ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform, and websites for unpublished literature, including conference abstracts. SELECTION CRITERIA We included randomized controlled trials (RCTs) that compared rapid ART versus standard care in people living with HIV. Children, adults, and adolescents from any setting were eligible for inclusion. DATA COLLECTION AND ANALYSIS Two review authors independently assessed the eligibility of the studies identified in the search, assessed the risk of bias and extracted data. The primary outcomes were mortality and virological suppression at 12 months. We have presented all outcomes using risk ratios (RR), with 95% confidence intervals (CIs). Where appropriate, we pooled the results in meta-analysis. We assessed the certainty of the evidence using the GRADE approach. MAIN RESULTS We included seven studies with 18,011 participants in the review. All studies were carried out in low- and middle-income countries in adults aged 18 years old or older. Only one study included pregnant women.In all the studies, the rapid ART intervention was offered as part of a package that included several cointerventions targeting individuals, health workers and health system processes delivered alongside rapid ART that aimed to facilitate uptake and adherence to ART.Comparing rapid ART with standard initiation probably results in greater viral suppression at 12 months (RR 1.18, 95% CI 1.10 to 1.27; 2719 participants, 4 studies; moderate-certainty evidence) and better ART uptake at 12 months (RR 1.09, 95% CI 1.06 to 1.12; 3713 participants, 4 studies; moderate-certainty evidence), and may improve retention in care at 12 months (RR 1.22, 95% CI 1.11 to 1.35; 5001 participants, 6 studies; low-certainty evidence). Rapid ART initiation was associated with a lower mortality estimate, however the CIs included no effect when compared to standard of care (RR 0.72, 95% CI 0.51 to 1.01; 5451 participants, 7 studies; very low-certainty evidence). It is uncertain whether rapid ART has an effect on modification of ART treatment regimens as data are lacking (RR 7.89, 95% CI 0.76 to 81.74; 977 participants, 2 studies; very low-certainty evidence). There was insufficient evidence to draw conclusions on the occurrence of adverse events. AUTHORS' CONCLUSIONS RCTs that include initiation of ART within one week of diagnosis appear to improve outcomes across the HIV treatment cascade in low- and middle-income settings. The studies demonstrating these effects delivered rapid ART combined with several setting-specific cointerventions. This highlights the need for pragmatic research to identify feasible packages that assure the effects seen in the trials when delivered through complex health systems.
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Affiliation(s)
- Alberto Mateo-Urdiales
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK, L3 5QA
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Harklerode R, Waruiru W, Humwa F, Waruru A, Kellogg T, Muthoni L, Macharia J, Zielinski-Gutierrez E. Epidemiological profile of individuals diagnosed with HIV: results from the preliminary phase of case-based surveillance in Kenya. AIDS Care 2019; 32:43-49. [PMID: 31032628 DOI: 10.1080/09540121.2019.1612021] [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: 10/26/2022]
Abstract
Understanding the characteristics of individuals who are newly diagnosed with HIV is critical to controlling the HIV epidemic. Characterizing this population can improve strategies to identify undiagnosed positives and assist in targeting the provision of HIV services to improve health outcomes. We describe the characteristics of newly diagnosed HIV cases in western Kenya from 124 health facilities. The study cohort cases were matched to prevent duplication and patients newly diagnosed between January and June 2015 were identified and descriptive analysis performed. Among 8664 newly identified HIV cases, during the pilot timeframe, 3.1% (n=265) had retested for HIV after initial diagnosis. Linkage to care was recorded for approximately half (45.3%, n = 3930) and 28.0% (n = 2425) had a CD4 count available during the pilot timeframe. The median baseline CD4 count was 332 cells/mL (IQR: 156-544). Among the newly diagnosed age 15 years or older with a CD4 test, 53.0% (n = 1216) were diagnosed late, including 32.9% (n = 755) who had advanced HIV at diagnosis. Factors associated with late diagnosis included being male and in an age group older than 34 years. In western Kenya, continued efforts are needed in the area of testing to enhance early HIV diagnosis and epidemic control.
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Affiliation(s)
- Richelle Harklerode
- Global Health Sciences, University of California San Francisco, San Francisco, CA, USA
| | - Wanjiru Waruiru
- Global Programs for Research and Training, University of California San Francisco, Nairobi, Kenya
| | - Felix Humwa
- Global Programs for Research and Training, University of California San Francisco, Nairobi, Kenya
| | - Anthony Waruru
- Division of Global HIV & TB, U.S. Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Timothy Kellogg
- Global Health Sciences, University of California San Francisco, San Francisco, CA, USA
| | - Lilly Muthoni
- National AIDS and STI Control Program, Ministry of Health, Nairobi, Kenya
| | - James Macharia
- Global Programs for Research and Training, University of California San Francisco, Nairobi, Kenya
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Sanga ES, Mukumbang FC, Mushi AK, Lerebo W, Zarowsky C. Understanding factors influencing linkage to HIV care in a rural setting, Mbeya, Tanzania: qualitative findings of a mixed methods study. BMC Public Health 2019; 19:383. [PMID: 30953503 PMCID: PMC6451278 DOI: 10.1186/s12889-019-6691-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 03/21/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND In remote rural Tanzania, the rate of linkage into HIV care was estimated at 28% in 2014. This study explored facilitators and barriers to linkage to HIV care at individual/patient, health care provider, health system, and contextual levels to inform eventual design of interventions to improve linkage to HIV care. METHODS We conducted a descriptive qualitative study nested in a cohort study of 1012 newly diagnosed HIV-positive individuals in Mbeya region between August 2014 and July 2015. We conducted 8 focus group discussions and 10 in-depth interviews with recently diagnosed HIV-positive individuals and 20 individual interviews with healthcare providers. Transcripts were analyzed inductively using thematic content analysis. The emergent themes were then deductively fitted into the four level ecological model. RESULTS We identified multiple factors influencing linkage to care. HIV status disclosure, support from family/relatives and having symptoms of disease were reported to facilitate linkage at the individual level. Fear of stigma, lack of disclosure, denial and being asymptomatic, belief in witchcraft and spiritual beliefs were barriers identified at individual's level. At providers' level; support and good patient-staff relationship facilitated linkage, while negative attitudes and abusive language were reported barriers to successful linkage. Clear referral procedures and well-organized clinic procedures were system-level facilitators, whereas poorly organized clinic procedures and visit schedules, overcrowding, long waiting times and lack of resources were reported barriers. Distance and transport costs to HIV care centers were important contextual factors influencing linkage to care. CONCLUSION Linkage to HIV care is an important step towards proper management of HIV. We found that access and linkage to care are influenced positively and negatively at all levels, however, the individual-level and health system-level factors were most prominent in this setting. Interventions must address issues around stigma, denial and inadequate awareness of the value of early linkage to care, and improve the capacity of HIV treatment/care clinics to implement quality care, particularly in light of adopting the 'Test and Treat' model of HIV treatment and care recommended by the World Health Organization.
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Affiliation(s)
- Erica S Sanga
- NIMR-Mwanza Medical Research Centre, P.O Box 1462, Mwanza, Tanzania. .,School of Public Health- University of Western Cape, Cape Town, South Africa. .,NIMR-Mwanza Medical Research Centre (MMRC), Mbeya, Tanzania.
| | - Ferdinand C Mukumbang
- School of Public Health- University of Western Cape, Cape Town, South Africa.,Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Adiel K Mushi
- National Institute for Medical Research (NIMR), London, England
| | - Wondwossen Lerebo
- School of Public Health- University of Western Cape, Cape Town, South Africa.,School of Public Health, Mekelle University, Makelle, Ethiopia
| | - Christina Zarowsky
- School of Public Health- University of Western Cape, Cape Town, South Africa.,University of Montreal Hospital Research Centre and School of Public Health, Universite de Montreal, Montreal, Canada
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DiCarlo AL, Gachuhi AB, Mthethwa-Hleta S, Shongwe S, Hlophe T, Peters ZJ, Zerbe A, Myer L, Langwenya N, Okello V, Sahabo R, Nuwagaba-Biribonwoha H, Abrams EJ. Healthcare worker experiences with Option B+ for prevention of mother-to-child HIV transmission in eSwatini: findings from a two-year follow-up study. BMC Health Serv Res 2019; 19:210. [PMID: 30940149 PMCID: PMC6444445 DOI: 10.1186/s12913-019-3997-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Accepted: 03/07/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Prevention of mother-to-child transmission (PMTCT) across sub-Saharan Africa has rapidly shifted towards Option B+, an approach in which all HIV+ pregnant and breastfeeding women initiate lifelong antiretroviral therapy (ART) independent of CD4+ count. Healthcare workers (HCW) are critical to the success of Option B+, yet little is known regarding HCW acceptability of Option B+, particularly over time. METHODS Ten health facilities in the Manzini and Lubombo regions of eSwatini transitioned from Option A to Option B+ between 2013 and 2014 as part of the Safe Generations study examining PMTCT retention. Fifty HCWs (5 per facility) completed questionnaires assessing feasibility and acceptability: (1) prior to transitioning to Option B+, (2) two months post transition, and (3) approximately 2 years post Option B+ transition. This analysis describes HCW perceptions and experiences two years after transitioning to Option B+. RESULTS Two years after transition, 80% of HCWs surveyed reported that Option B+ was easy for HCWs, noting that it was particularly easy to explain and coordinate. Immediate ART initiation also reduced delays by eliminating need for laboratory tests prior to ART initiation. Additionally, HCWs reported ease of patient follow-up (58%), documentation (56%), and counseling (58%) under Option B+. Findings also indicate that a majority of HCWs reported that their workloads increased under Option B+. Sixty-eight percent of HCWs at two years post-transition reported more work under Option B+, specifically noting increased involvement in adherence counseling, prescribing/monitoring medications, and appointment scheduling/tracking. Some HCWs attributed their higher workloads to increased client loads, now that all HIV-positive women were initiated on ART. New barriers to patient uptake, and issues related to retention, adherence, and follow-up were also noted as challenges face by HCW when implementing Option B+. CONCLUSIONS Overall, HCWs found Option B+ to be acceptable and feasible while providing critical insights into the practical issues of universal ART. Further strengthening of the healthcare system may be necessary to alleviate worker burden and to ensure effective monitoring of client retention and adherence. HCW perceptions and experiences with Option B+ should be considered more broadly as countries implement Option B+ and consider universal treatment for all HIV+ individuals. TRIAL REGISTRATION http://clinicaltrials.gov NCT01891799 , registered on July 3, 2013.
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Affiliation(s)
- Abby L. DiCarlo
- ICAP at Columbia University, Mailman School of Public Health, New York, NY USA
| | | | | | - Siphesihle Shongwe
- ICAP at Columbia University, Mailman School of Public Health, New York, NY USA
| | - Thabo Hlophe
- ICAP at Columbia University, Mailman School of Public Health, New York, NY USA
| | - Zachary J. Peters
- ICAP at Columbia University, Mailman School of Public Health, New York, NY USA
| | - Allison Zerbe
- ICAP at Columbia University, Mailman School of Public Health, New York, NY USA
| | - Landon Myer
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
- Centre for Infectious Diseases Epidemiology & Research, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Nontokozo Langwenya
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
- Centre for Infectious Diseases Epidemiology & Research, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Ruben Sahabo
- ICAP at Columbia University, Mailman School of Public Health, New York, NY USA
| | | | - Elaine J. Abrams
- ICAP at Columbia University, Mailman School of Public Health, New York, NY USA
- Vagelos College of Physicians & Surgeons, Columbia University, New York, NY USA
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35
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Sanga ES, Mukumbang FC, Mushi AK, Olomi W, Lerebo W, Zarowsky C. Processes and dynamics of linkage to care from mobile/outreach and facility-based HIV testing models in hard-to-reach settings in rural Tanzania. Qualitative findings of a mixed methods study. AIDS Res Ther 2018; 15:21. [PMID: 30458874 DOI: 10.1186/s12981-018-0209-8n.pag-n.pag] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 11/08/2018] [Indexed: 05/22/2023] Open
Abstract
BACKGROUND Like other countries, Tanzania instituted mobile and outreach testing approaches to address low HIV testing rates at health facilities and enhance linkage to care. Available evidence from hard-to-reach rural settings of Mbeya region, Tanzania suggests that clients testing HIV+ at facility-based sites are more likely to link to care, and to link sooner, than those testing at mobile sites. This paper (1) describes the populations accessing HIV testing at mobile/outreach and facility-based testing sites, and (2) compares processes and dynamics from testing to linkage to care between these two testing models from the same study context. METHODS An explanatory sequential mixed-method study (a) reviewed records of all clients (n = 11,773) testing at 8 mobile and 8 facility-based testing sites over 6 months; (b), reviewed guidelines; (c) observed HIV testing sites (n = 10) and Care and Treatment Centers (CTCs) (n = 8); (d) applied questionnaires at 0, 3 and 6 months to a cohort of 1012 HIV newly-diagnosed clients from the 16 sites; and (e) conducted focus group discussions (n = 8) and in-depth qualitative interviews with cohort members (n = 10) and health care providers (n = 20). RESULTS More clients tested at mobile/outreach than facility-based sites (56% vs 44% of 11,733, p < 0.001). Mobile site clients were more likely to be younger and male (p < 0.001). More clients testing at facility sites were HIV positive (21.5% vs. 7.9% of 11,733, p < 0.001). All sites in both testing models adhered to national HIV testing and care guidelines. Staff at mobile sites showed more proactive efforts to support linkage to care, and clients report favouring the confidentiality of mobile sites to avoid stigma. Clients who tested at mobile/outreach sites faced longer delays and waiting times at treatment sites (CTCs). CONCLUSIONS Rural mobile/outreach HIV testing sites reach more people than facility based sites but they reach a different clientèle which is less likely to be HIV +ve and appears to be less "linkage-ready". Despite more proactive care and confidentiality at mobile sites, linkage to care is worse than for clients who tested at facility-based sites. Our findings highlight a combination of (a) patient-level factors, including stigma; and (b) well-established procedures and routines for each step between testing and initiation of treatment in facility-based sites. Long waiting times at treatment sites are a further barrier that must be addressed.
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Affiliation(s)
- Erica S Sanga
- NIMR-Mwanza Medical Research Centre (MMRC), Mwanza, Tanzania.
- School of Public Health, University of Western Cape, Cape Town, South Africa.
- NIMR-Mbeya Medical Research Centre (MMRC), Mbeya, Tanzania.
| | - Ferdinand C Mukumbang
- School of Public Health, University of Western Cape, Cape Town, South Africa
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Adiel K Mushi
- National Institute for Medical Research (NIMR), Dar-es-Salaam, Tanzania
| | | | - Wondwossen Lerebo
- School of Public Health, University of Western Cape, Cape Town, South Africa
- School of Public Health, Mekelle University, Mekelle, Ethiopia
| | - Christina Zarowsky
- School of Public Health, University of Western Cape, Cape Town, South Africa
- University of Montreal Hospital Research Centre and School of Public Health, Université de Montréal, Montreal, Canada
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36
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Processes and dynamics of linkage to care from mobile/outreach and facility-based HIV testing models in hard-to-reach settings in rural Tanzania. Qualitative findings of a mixed methods study. AIDS Res Ther 2018; 15:21. [PMID: 30458874 PMCID: PMC6247671 DOI: 10.1186/s12981-018-0209-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 11/08/2018] [Indexed: 12/23/2022] Open
Abstract
Background Like other countries, Tanzania instituted mobile and outreach testing approaches to address low HIV testing rates at health facilities and enhance linkage to care. Available evidence from hard-to-reach rural settings of Mbeya region, Tanzania suggests that clients testing HIV+ at facility-based sites are more likely to link to care, and to link sooner, than those testing at mobile sites. This paper (1) describes the populations accessing HIV testing at mobile/outreach and facility-based testing sites, and (2) compares processes and dynamics from testing to linkage to care between these two testing models from the same study context. Methods An explanatory sequential mixed-method study (a) reviewed records of all clients (n = 11,773) testing at 8 mobile and 8 facility-based testing sites over 6 months; (b), reviewed guidelines; (c) observed HIV testing sites (n = 10) and Care and Treatment Centers (CTCs) (n = 8); (d) applied questionnaires at 0, 3 and 6 months to a cohort of 1012 HIV newly-diagnosed clients from the 16 sites; and (e) conducted focus group discussions (n = 8) and in-depth qualitative interviews with cohort members (n = 10) and health care providers (n = 20). Results More clients tested at mobile/outreach than facility-based sites (56% vs 44% of 11,733, p < 0.001). Mobile site clients were more likely to be younger and male (p < 0.001). More clients testing at facility sites were HIV positive (21.5% vs. 7.9% of 11,733, p < 0.001). All sites in both testing models adhered to national HIV testing and care guidelines. Staff at mobile sites showed more proactive efforts to support linkage to care, and clients report favouring the confidentiality of mobile sites to avoid stigma. Clients who tested at mobile/outreach sites faced longer delays and waiting times at treatment sites (CTCs). Conclusions Rural mobile/outreach HIV testing sites reach more people than facility based sites but they reach a different clientèle which is less likely to be HIV +ve and appears to be less “linkage-ready”. Despite more proactive care and confidentiality at mobile sites, linkage to care is worse than for clients who tested at facility-based sites. Our findings highlight a combination of (a) patient-level factors, including stigma; and (b) well-established procedures and routines for each step between testing and initiation of treatment in facility-based sites. Long waiting times at treatment sites are a further barrier that must be addressed.
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37
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Mwamba C, Sharma A, Mukamba N, Beres L, Geng E, Holmes CB, Sikazwe I, Topp SM. 'They care rudely!': resourcing and relational health system factors that influence retention in care for people living with HIV in Zambia. BMJ Glob Health 2018; 3:e001007. [PMID: 30483408 PMCID: PMC6231098 DOI: 10.1136/bmjgh-2018-001007] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 08/08/2018] [Accepted: 08/31/2018] [Indexed: 01/27/2023] Open
Abstract
INTRODUCTION Despite access to free antiretroviral therapy (ART), many HIV-positive Zambians disengage from HIV care. We sought to understand how Zambian health system 'hardware' (tangible components) and 'software' (work practices and behaviour) influenced decisions to disengage from care among 'lost-to-follow-up' patients traced by a larger study on their current health status. METHODS We purposively selected 12 facilities, from 4 provinces. Indepth interviews were conducted with 69 patients across four categories: engaged in HIV care, disengaged from care, transferred to another facility and next of kin if deceased. We also conducted 24 focus group discussions with 158 lay and professional healthcare workers (HCWs). These data were triangulated against two consecutive days of observation conducted in each facility. We conducted iterative multilevel analysis using inductive and deductive reasoning. RESULTS Health system 'hardware' factors influencing patients' disengagement included inadequate infrastructure to protect privacy; distance to health facilities which costs patients time and money; and chronic understaffing which increased wait times. Health system 'software' factors related to HCWs' work practices and clinical decisions, including delayed opening times, file mismanagement, drug rationing and inflexibility in visit schedules, increased wait times, number of clinic visits, and frustrated access to care. While patients considered HCWs as 'mentors' and trusted sources of information, many also described them as rude, tardy, careless with details and confidentiality, and favouring relatives. Nonetheless, unlike previously reported, many patients preferred ART over alternative treatment (eg, traditional medicine) for its perceived efficacy, cost-free availability and accompanying clinical monitoring. CONCLUSION Findings demonstrate the dynamic effect of health system 'hardware' and 'software' factors on decisions to disengage. Our findings suggest a need for improved: physical resourcing and structuring of HIV services, preservice and inservice HCWs and management training and mentorship programmes to encourage HCWs to provide 'patient-centered' care and exercise 'flexibility' to meet patients' varying needs and circumstances.
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Affiliation(s)
- Chanda Mwamba
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Anjali Sharma
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Njekwa Mukamba
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Laura Beres
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Elvin Geng
- School of Medicine, University of California, San Francisco, California, USA
| | - Charles B Holmes
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Izukanji Sikazwe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Stephanie M Topp
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- College of Public Health Medical and Veterinary Sciences, James Cook University, Townsville, Queensland, Australia
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Perceptions and decision-making with regard to pregnancy among HIV positive women in rural Maputo Province, Mozambique - a qualitative study. BMC WOMENS HEALTH 2018; 18:166. [PMID: 30305066 PMCID: PMC6180632 DOI: 10.1186/s12905-018-0644-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Accepted: 09/12/2018] [Indexed: 12/04/2022]
Abstract
Background In preventing the transfer of HIV to their children, the Ministry of Health in Mozambique recommends all couples follow medical advice prior to a pregnancy. However, little is known about how such women experience pregnancy, nor the values they adhere to when making childbearing decisions. This qualitative study explores perceptions and decision-making processes regarding pregnancy among HIV positive women in rural Maputo Province. Methods In-depth interviews and five focus group discussions with fifty-nine women who had recently become mothers were carried out. In addition, six semi-structured interviews were held with maternity and child health nurses. The ethnographic methods employed here were guided by Bourdieu’s practice theory. Results The study indicated that women often perceived pregnancy as a test of fertility and identity. It was not only viewed as a rite of passage from childhood to womanhood, but also as a duty for married women to have children. Most women did not follow recommended medical advice prior to gestation. This was primarily due to perceptions that decision-making about pregnancy was regarded as a private issue not requiring consultation with a healthcare provider. Additionally, stigmatisation of women living with HIV, lack of knowledge about the need to consult a healthcare provider prior to pregnancy, and unintended pregnancy due to inadequate use of contraceptive were crucial factors. Conclusion Women’s experiences and decisions regarding pregnancy are more influenced by social and cultural norms than medical advice. Therefore, education concerning sexual and reproductive health in relation to HIV/AIDS and childbearing is recommended. In particular, we recommend maternal and child healthcare nurses need to be sensitive to women’s perceptions and the cultural context of maternity when providing information about sexual and reproductive health.
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Preferences for linkage to HIV care services following a reactive self-test: discrete choice experiments in Malawi and Zambia. AIDS 2018; 32:2043-2049. [PMID: 29894386 DOI: 10.1097/qad.0000000000001918] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVES The current research identifies key drivers of demand for linkage into care following a reactive HIV self-test result in Malawi and Zambia. Preferences are explored among the general population and key groups such as HIV-positive individuals and adolescents. DESIGN We used discrete choice experiments (DCEs) embedded in representative household surveys to quantify the relative strength of preferences for various HIV services characteristics. METHODS The DCE was designed on the basis of a literature review and qualitative studies. Data were collected within a survey (Malawi n = 553, Zambia n = 388), pooled across country and analysed using mixed logit models. Preference heterogeneity was explored by country, age, sex, wealth, HIV status and belief that HIV treatment is effective. RESULTS DCE results were largely consistent across countries. Major barriers for linkage were fee-based testing and long wait for testing. Community-based confirmatory testing, that is at the participant's or counsellor's home, was preferred to facility-based confirmation. Providing separated waiting areas for HIV services at health facilities and mobile clinics was positively viewed in Malawi but not in Zambia. Active support for linkage was less important to respondents than other attributes. Preference heterogeneity was identified: overall, adolescents were more willing to seek care than adults, whereas HIV-positive participants were more likely to link at health facilities with separate HIV services. CONCLUSION Populations in Malawi and in Zambia were responsive to low-cost, HIV care services with short waiting time provided either at the community or privately at health facilities. Hard-to-reach groups could be encouraged to link to care with targeted support.
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Ahmed S, Autrey J, Katz IT, Fox MP, Rosen S, Onoya D, Bärnighausen T, Mayer KH, Bor J. Why do people living with HIV not initiate treatment? A systematic review of qualitative evidence from low- and middle-income countries. Soc Sci Med 2018; 213:72-84. [PMID: 30059900 PMCID: PMC6813776 DOI: 10.1016/j.socscimed.2018.05.048] [Citation(s) in RCA: 69] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Revised: 05/15/2018] [Accepted: 05/25/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Many people living with HIV (PLWH) who are eligible for antiretroviral therapy (ART) do not initiate treatment, leading to excess morbidity, mortality, and viral transmission. As countries move to treat all PLWH at diagnosis, it is critical to understand reasons for non-initiation. METHODS We conducted a systematic review of the qualitative literature on reasons for ART non-initiation in low- and middle-income countries. We screened 1376 titles, 680 abstracts, and 154 full-text reports of English-language qualitative studies published January 2000-April 2017; 20 met criteria for inclusion. Our analysis involved three steps. First, we used a "thematic synthesis" approach, identifying supply-side (facility) and demand-side (patient) factors commonly cited across different studies and organizing these factors into themes. Second, we conducted a theoretical mapping exercise, developing an explanatory model for patients' decision-making process to start (or not to start) ART, based on inductive analysis of evidence reviewed. Third, we used this explanatory model to identify opportunities to intervene to increase ART uptake. RESULTS Demand-side factors implicated in decisions not to start ART included feeling healthy, low social support, gender norms, HIV stigma, and difficulties translating intentions into actions. Supply-side factors included high care-seeking costs, concerns about confidentiality, low-quality health services, recommended lifestyle changes, and incomplete knowledge of treatment benefits. Developing an explanatory model, which we labeled the Transdisciplinary Model of Health Decision-Making, we posited that contextual factors determine the costs and benefits of ART; patients perceive this context (through cognitive and emotional appraisals) and form an intention whether or not to start; and these intentions may (or may not) be translated into actions. Interventions can target each of these three stages. CONCLUSIONS Reasons for not starting ART included consistent themes across studies. Future interventions could: (1) provide information on the large health and prevention benefits of ART and the low side effects of current regimens; (2) reduce stigma at the patient and community levels and increase confidentiality where stigma persists; (3) remove lifestyle requirements and support patients in integrating ART into their lives; and (4) alleviate economic burdens of ART. Interventions addressing reasons for non-initiation will be critical to the success of HIV "treat all" strategies.
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Affiliation(s)
- Shahira Ahmed
- Department of Global Health, Boston University School of Public Health, Boston, United States
| | - Jessica Autrey
- Department of Global Health, Boston University School of Public Health, Boston, United States
| | - Ingrid T Katz
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States; Massachusetts General Hospital, Center for Global Health, Boston, MA, United States
| | - Matthew P Fox
- Department of Global Health, Boston University School of Public Health, Boston, United States; Department of Epidemiology, Boston University School of Public Health, Boston, United States; Health Economics and Epidemiology Research Office, Wits Health Consortium, Faculty of Medical Sciences, University of the Witwatersrand Medical School, Johannesburg, South Africa
| | - Sydney Rosen
- Department of Global Health, Boston University School of Public Health, Boston, United States; Health Economics and Epidemiology Research Office, Wits Health Consortium, Faculty of Medical Sciences, University of the Witwatersrand Medical School, Johannesburg, South Africa
| | - Dorina Onoya
- Health Economics and Epidemiology Research Office, Wits Health Consortium, Faculty of Medical Sciences, University of the Witwatersrand Medical School, Johannesburg, South Africa
| | - Till Bärnighausen
- Heidelberg Institute of Public Health, University of Heidelberg, Heidelberg, Germany; Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, United States; Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - Kenneth H Mayer
- Harvard Medical School, Boston, MA, United States; The Fenway Institute, Boston, United States
| | - Jacob Bor
- Department of Global Health, Boston University School of Public Health, Boston, United States; Department of Epidemiology, Boston University School of Public Health, Boston, United States; Health Economics and Epidemiology Research Office, Wits Health Consortium, Faculty of Medical Sciences, University of the Witwatersrand Medical School, Johannesburg, South Africa; Africa Health Research Institute, KwaZulu-Natal, South Africa.
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Wachira J, Genberg B, Kafu C, Koech B, Akinyi J, Owino RK, Laws MB, Wilson IB, Braitstein P. The Perspective of HIV Providers in Western Kenya on Provider-Patient Relationships. JOURNAL OF HEALTH COMMUNICATION 2018; 23:591-596. [PMID: 29979930 PMCID: PMC6094379 DOI: 10.1080/10810730.2018.1493061] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Enhancing effective adherence dialogue with HIV patients in an environment that promotes good provider-patient relationships, is key to optimizing the benefits of antiretroviral therapy (ART). The study examines the perspectives of HIV providers in western Kenya on provider-patient relationships. Sixty healthcare providers were sampled using convenience sampling methods from three Academic Model for Providing Access to Healthcare (AMPATH) sites (one urban and two rural). In-depth interviews conducted in either Swahili or English were audio recorded, transcribed, and translated into English. Content analysis was performed after thematic coding. Providers perceived that they had good relationships with most patients, and tended to identify negative patient attributes as the source of poor provider-patient relationships. Providers preferred patients who adhered to treatment guidelines. They did not like patients who challenged their authority, and did not see it as their responsibility to find more effective ways of interacting with patients who they found difficult. Structural barriers to collaborative physician-patient relationships included noncontinuity of relationships, lack of specific appointment times, high provider-patient ratio, and management of provider fatigue and job dissatisfaction. There is need for HIV care programs to identify culturally appropriate interventions to enhance better provider-patient relationship.
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Affiliation(s)
- Juddy Wachira
- a School of Medicine , Moi University , Eldoret , Kenya
- b Academic Model Providing Access to Healthcare (AMPATH) Partnership , Eldoret , Kenya
| | - Becky Genberg
- c Bloomberg School of Public Health , Johns Hopkins University , Baltimore , MD , USA
| | - Catherine Kafu
- b Academic Model Providing Access to Healthcare (AMPATH) Partnership , Eldoret , Kenya
| | - Beatrice Koech
- b Academic Model Providing Access to Healthcare (AMPATH) Partnership , Eldoret , Kenya
| | - Jacqueline Akinyi
- b Academic Model Providing Access to Healthcare (AMPATH) Partnership , Eldoret , Kenya
| | - Regina K Owino
- b Academic Model Providing Access to Healthcare (AMPATH) Partnership , Eldoret , Kenya
| | - Michael Barton Laws
- d Department of Health Services, Policy & Practice , Brown University , Providence, RI, USA
| | - Ira B Wilson
- d Department of Health Services, Policy & Practice , Brown University , Providence, RI, USA
| | - Paula Braitstein
- e Dalla Lana School of Public Health , University of Toronto , Toronto, Ontario , Canada
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Cluver L, Meinck F, Toska E, Orkin FM, Hodes R, Sherr L. Multitype violence exposures and adolescent antiretroviral nonadherence in South Africa. AIDS 2018; 32:975-983. [PMID: 29547438 PMCID: PMC6037279 DOI: 10.1097/qad.0000000000001795] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 02/11/2018] [Accepted: 02/26/2018] [Indexed: 11/25/2022]
Abstract
OBJECTIVES HIV-positive adolescents have low-ART adherence, with consequent increased risks of mortality, morbidity, and viral resistance. Despite high rates of violence against children in the Africa region, no known studies have tested impacts on HIV-positive adolescents. We examine associations of ART adherence with adolescent violence victimization by caregivers, teachers, peers, community members, and healthcare providers. DESIGN AND METHODS HIV-positive adolescents were interviewed (n = 1060), and clinic biomarker data collected. We sampled all 10-19-year olds ever ART-initiated within 53 clinics in 180 South African communities (90.1% reached). Analyses examined associations between nonadherence and nine violence types using sequential multivariate logistic regressions. Interactive and additive effects were tested with regression and marginal effects. RESULTS Past-week self-reported ART nonadherence was 36%. Nonadherence correlated strongly with virologic failure (OR 2.3, CI 1.4-3.8) and symptomatic pulmonary tuberculosis (OR 1.49, CI 1.18-2.05). Four violence types were independently associated with nonadherence: physical abuse by caregivers (OR 1.5, CI 1.1-2.1); witnessing domestic violence (OR 1.8, CI 1.22-2.66); teacher violence (OR 1.51, CI 1.16-1.96,) and verbal victimization by healthcare staff (OR 2.15, CI 1.59-2.93). Past-week nonadherence rose from 25% with no violence to 73.5% with four types of violence exposure. CONCLUSION Violence exposures at home, school, and clinic are major and cumulating risks for adolescent antiretroviral nonadherence. Prevention, mitigation, and protection services may be essential for the health and survival of HIV-positive adolescents.
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Affiliation(s)
- Lucie Cluver
- Centre for Evidence-Based Intervention, Department of Social Policy & Intervention, University of Oxford, UK
- Department of Psychiatry and Mental Health, University of Cape Town
| | - Franziska Meinck
- Centre for Evidence-Based Intervention, Department of Social Policy & Intervention, University of Oxford, UK
- OPTENTIA Research Focus Group, School of Behavioural Sciences, North-West University, Vanderbeijlpark
| | - Elona Toska
- AIDS and Society Research Unit, Centre for Social Science Research, University of Cape Town
| | - F. Mark Orkin
- Centre for Evidence-Based Intervention, Department of Social Policy & Intervention, University of Oxford, UK
- MRC Development Pathways to Health Research Unit, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Rebecca Hodes
- AIDS and Society Research Unit, Centre for Social Science Research, University of Cape Town
| | - Lorraine Sherr
- Department of Global Health, University College London, UK
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Mateo-Urdiales A, Johnson S, Nachega JB, Eshun-Wilson I. Rapid initiation of antiretroviral therapy for people living with HIV. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2018. [DOI: 10.1002/14651858.cd012962] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Alberto Mateo-Urdiales
- Liverpool School of Tropical Medicine; Department of Clinical Sciences; Liverpool UK L3 5QA
| | - Samuel Johnson
- Liverpool School of Tropical Medicine; Department of Clinical Sciences; Liverpool UK L3 5QA
| | - Jean B Nachega
- University of Pittsburgh; Department of Epidemiology, Infectious Diseases and Microbiology; Pittsburgh Pennsylvania USA
- Johns Hopkins Bloomberg School of Public Health; Department of Epidemiology and International Health; Baltimore Maryland USA
- Stellenbosch University; Centre for Infectious Diseases; Cape Town South Africa
| | - Ingrid Eshun-Wilson
- Stellenbosch University; Centre for Evidence Based Health Care, Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences; Francie van Zyl Drive, Tygerberg, 7505, Parow Cape Town Western Cape South Africa 7505
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Bor J, Chiu C, Ahmed S, Katz I, Fox MP, Rosen S, Yapa M, Tanser F, Pillay D, Bärnighausen T. Failure to initiate HIV treatment in patients with high CD4 counts: evidence from demographic surveillance in rural South Africa. Trop Med Int Health 2018; 23:206-220. [PMID: 29160949 PMCID: PMC5829292 DOI: 10.1111/tmi.13013] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVES To assess the relationship between CD4 count at presentation and ART uptake and assess predictors of timely treatment initiation in rural KwaZulu-Natal, South Africa. METHODS We used Kaplan-Meier and Cox proportional hazards models to assess the association between first CD4 count and time from first CD4 to ART initiation among all adults presenting to the Hlabisa HIV Treatment and Care Programme between August 2011 and December 2012 with treatment-eligible CD4 counts (≤ 350 cells/mm3 ). For a subset of healthier patients (200 < CD4 ≤ 350 cells) residing within the population surveillance of the Africa Health Research Institute, we assessed sociodemographic, economic and geographic predictors hypothesised to influence ART uptake. RESULTS A total of 4739 patients presented for care with eligible CD4 counts. The proportion initiating ART within six months of diagnosis was 67% (95% CI 63, 71) in patients with CD4 ≤ 50, 59% (0.55, 0.63) in patients with CD4 151-200 and 48% (95% CI 44, 51) in patients with CD4 301-350. The hazard of starting ART fell by 17% (95% CI 14, 20) for every 100-cell increase in baseline CD4 count. Among healthier patients under demographic surveillance (n = 193), observable sociodemographic, economic and geographic predictors did not add discriminatory power beyond CD4 count, age and sex to identify patients at high risk of non-initiation. CONCLUSIONS Individuals presenting for HIV care at higher CD4 counts were less likely to initiate ART than patients presenting at low CD4 counts. Overall, ART uptake was low. Under new guidelines that establish ART eligibility regardless of CD4 count, patients with high CD4 counts may require additional interventions to encourage treatment initiation.
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Affiliation(s)
- Jacob Bor
- 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
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Calvin Chiu
- 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
| | - Shahira Ahmed
- 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
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | - Ingrid Katz
- Division of Women's Health, Brigham and Women's Hospital, Boston, MA, USA
- Center for Global Health, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Matthew P Fox
- 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
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Sydney Rosen
- 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
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | - Manisha Yapa
- Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - Frank Tanser
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
- Research Department of Infection & Population Health, University College London, London, United Kingdom
| | - Deenan Pillay
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- Department of Virology, University College London, London, United Kingdom
| | - Till Bärnighausen
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- Research Department of Infection & Population Health, University College London, London, United Kingdom
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
- Institute of Public Health, University of Heidelberg, Heidelberg, Germany
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Wachira J, Genberg B, Kafu C, Braitstein P, Laws MB, Wilson IB. Experiences and expectations of patients living with HIV on their engagement with care in Western Kenya. Patient Prefer Adherence 2018; 12:1393-1400. [PMID: 30122904 PMCID: PMC6078080 DOI: 10.2147/ppa.s168664] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE In resource-limited HIV care settings, effective and innovative interventions that respond to the existing challenges along the HIV care continuum are urgently needed to realize the benefits of antiretroviral therapy (ART). Initiating effective ART adherence dialog in an environment that promotes patient engagement in care is key. It is therefore critical to enhance our understanding about how patients living with HIV in these regions conceptualize and experience patient engagement. This study explores HIV patients' perceptions, experiences and expectations of their engagement in care. MATERIALS AND METHODS We sampled 86 patients from three Academic Model for Providing Access to Healthcare (AMPATHplus) sites, one urban and two rural. We conducted 24 in-depth interviews and eight focus group discussions in either Swahili or English. Audio recordings of the interviews were transcribed, and then translated into English. We performed content analysis after thematic coding. RESULTS Patients living with HIV in Kenya desire active engagement with care. However, their engagement was inconsistent and varied depending on the provider. Patients had a sense of how provider's interpersonal behaviors influenced their level of engagement. These included various aspects of provider-patient communication and relationship dynamics. Patients also highlighted relational boundaries that influenced the level and kind of information they shared with their providers. Aspects of their psychological, social or economic wellbeing were often viewed as personal and not discussed with their clinicians. Patients identified factors that would promote or impede their engagement with care including those related to patients themselves, providers, and the healthcare system. CONCLUSION Patients living with HIV desired more active engagement in their care. In addition, they desired clinicians to engage in more social behaviors to promote patient engagement. To address existing patient engagement barriers, HIV care systems in the region should apply contextualized patient-centered interventions.
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Affiliation(s)
- Juddy Wachira
- Department of Behavioral Sciences, School of Medicine, Moi University, Eldoret, Kenya,
- Department of Epidemiology, Bloomberg School of Public Health, John Hopkins University, Baltimore, MD, USA,
| | - Becky Genberg
- Academic Model Providing Access to Healthcare (AMPATH) Partnership, Eldoret, Kenya
| | - Catherine Kafu
- Department of Epidemiology, Bloomberg School of Public Health, John Hopkins University, Baltimore, MD, USA,
| | - Paula Braitstein
- Dalla Lana School of Public Health, University of Toronto, Ontario, Canada
| | - Michael Barton Laws
- Department of Health Services, Policy and Practice, Brown University, Providence, RI, USA
| | - Ira B Wilson
- Department of Health Services, Policy and Practice, Brown University, Providence, RI, USA
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Wilson KS, Mugo C, Bukusi D, Inwani I, Wagner AD, Moraa H, Owens T, Babigumira JB, Richardson BA, John-Stewart GC, Slyker JA, Wamalwa DC, Kohler PK. Simulated patient encounters to improve adolescent retention in HIV care in Kenya: study protocol of a stepped-wedge randomized controlled trial. Trials 2017; 18:619. [PMID: 29282109 PMCID: PMC5745919 DOI: 10.1186/s13063-017-2266-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Accepted: 10/20/2017] [Indexed: 11/15/2022] Open
Abstract
Background Adolescent-friendly policies aim to tailor HIV services for adolescents and young adults aged 10–24 years (AYA) to promote health outcomes and improve retention in HIV care and treatment. However, few interventions focus on improving healthcare worker (HCW) competencies and skills for provision of high-quality adolescent care. Standardized patients (SPs) are trained actors who work with HCWs in mock clinical encounters to improve clinical assessment, communication, and empathy skills. This stepped-wedge randomized controlled trial will evaluate a clinical training intervention utilizing SPs to improve HCW skills in caring for HIV-positive AYA, resulting in increased retention in care. Methods/design The trial will utilize a stepped-wedge design to evaluate a training intervention using SPs to train HCWs in assessment, communication, and empathy skills for AYA HIV care. We will recruit 24 clinics in Kenya with an active electronic medical record (EMR) system and at least 40 adolescents enrolled in HIV care per site. Stratified randomization by county will be used to assign clinics to one of four waves – time periods when they receive the intervention – with each wave including six clinics. From each clinic, up to 10 HCWs will participate in the training intervention. SP training includes didactic sessions in adolescent health, current guidelines, communication skills, and motivational interviewing techniques. HCW participants will rotate through seven standardized SP scenarios, followed by SP feedback, group debriefing, and remote expert evaluation. AYA outcomes will be assessed using routine clinic data. The primary outcome is AYA retention in HIV care, defined as returning for first follow-up visit within 6 months of presenting to care, or returning for a first follow-up visit after re-engagement in care in AYA with a previous history of being lost to follow-up. Secondary outcomes include HCW competency scores, AYA satisfaction with care, and AYA clinical outcomes including CD4 and viral load. Additional analyses will determine cost-effectiveness of the intervention. Discussion This trial will contribute valuable information to HIV programs in Kenya and other low-resource settings, providing a potentially scalable strategy to improve quality of care and retention in critical HIV services in this population. Trial registration ClinicalTrials.gov, ID: NCT02928900. Registered 26 August 2016. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-2266-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Kate S Wilson
- Department of Global Health, University of Washington, 325 9th Avenue, Box 359932, Seattle, WA, 98104, USA.
| | - Cyrus Mugo
- Department of Paediatrics and Child Health/Kenyatta National Hospital, University of Nairobi, Nairobi, Kenya
| | - David Bukusi
- VCT and HIV Prevention Unit/Youth Centre, Kenyatta National Hospital, Nairobi, Kenya
| | - Irene Inwani
- Department of Paediatrics and Child Health/Kenyatta National Hospital, University of Nairobi, Nairobi, Kenya
| | - Anjuli D Wagner
- Department of Global Health, University of Washington, 325 9th Avenue, Box 359932, Seattle, WA, 98104, USA
| | - Helen Moraa
- Department of Paediatrics and Child Health/Kenyatta National Hospital, University of Nairobi, Nairobi, Kenya
| | - Tamara Owens
- Clinical Skills and Simulation Center, Howard University Health Sciences, Washington DC, USA
| | - Joseph B Babigumira
- Department of Global Health, University of Washington, 325 9th Avenue, Box 359932, Seattle, WA, 98104, USA
| | | | - Grace C John-Stewart
- Department of Global Health, University of Washington, 325 9th Avenue, Box 359932, Seattle, WA, 98104, USA.,Department of Pediatrics, University of Washington, Seattle, WA, USA.,Department of Epidemiology, University of Washington, Seattle, WA, USA.,Department of Medicine, University of Washington, Seattle, WA, USA
| | - Jennifer A Slyker
- Department of Global Health, University of Washington, 325 9th Avenue, Box 359932, Seattle, WA, 98104, USA
| | - Dalton C Wamalwa
- Department of Paediatrics and Child Health/Kenyatta National Hospital, University of Nairobi, Nairobi, Kenya
| | - Pamela K Kohler
- Department of Global Health, University of Washington, 325 9th Avenue, Box 359932, Seattle, WA, 98104, USA.,Department of Psychosocial and Community Health, University of Washington, Seattle, WA, USA
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Luseno WK, Iritani B, Zietz S, Maman S, Mbai II, Otieno F, Ongili B, Hallfors DD. Experiences along the HIV care continuum: perspectives of Kenyan adolescents and caregivers. AFRICAN JOURNAL OF AIDS RESEARCH : AJAR 2017; 16:241-250. [PMID: 28978294 PMCID: PMC6138248 DOI: 10.2989/16085906.2017.1365089] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
To be effective, HIV programmes should be responsive to the unique needs of diverse groups of infected adolescents. We highlight a range of adolescent perspectives on HIV services, including those who acquired HIV perinatally or sexually and those who were either in care, had dropped out of care, or had never enrolled in care. We conducted semi-structured interviews with 29 adolescents (aged 15-19) and 14 caregivers in western Kenya. Data were analysed using a descriptive analytical approach. Adolescents who were successfully linked had a supportive adult present during diagnosis; tested during hospitalisation or treatment for a recurrent or severe illness; and initiated treatment soon after diagnosis. Barriers to retention included side effects from HIV drugs, pill burden, and limited access to clean water and nutritious food. Support in family, school, and health facility environments was key for diagnosis, linkage, and retention. We make recommendations that may improve adolescent engagement in HIV services.
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Affiliation(s)
- Winnie K. Luseno
- Pacific Institute for Research and Evaluation (PIRE), 101 Conner Dr., Ste 200, Chapel Hill, NC 27514
| | - Bonita Iritani
- Pacific Institute for Research and Evaluation (PIRE), 101 Conner Dr., Ste 200, Chapel Hill, NC 27514
| | - Susannah Zietz
- Pacific Institute for Research and Evaluation (PIRE), 101 Conner Dr., Ste 200, Chapel Hill, NC 27514
- University of North Carolina, Department of Health Behavior and Health Education, Chapel Hill, 27599
| | - Suzanne Maman
- University of North Carolina, Department of Health Behavior and Health Education, Chapel Hill, 27599
| | | | | | | | - Denise Dion Hallfors
- Pacific Institute for Research and Evaluation (PIRE), 101 Conner Dr., Ste 200, Chapel Hill, NC 27514
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Ngandu NK, Van Malderen C, Goga A, Speybroeck N. Wealth-related inequality in early uptake of HIV testing among pregnant women: an analysis of data from a national cross-sectional survey, South Africa. BMJ Open 2017; 7:e013362. [PMID: 28706083 PMCID: PMC5577866 DOI: 10.1136/bmjopen-2016-013362] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Revised: 04/01/2017] [Accepted: 04/18/2017] [Indexed: 12/04/2022] Open
Abstract
OBJECTIVES Wealth-related inequality across the South African antenatal HIV care cascade has not been considered in detail as a potential hindrance to eliminating mother-to-child HIV transmission (EMTCT). We aimed to measure wealth-related inequality in early (before enrolling into antenatal care) uptake of HIV testing and identify the contributing determinants. DESIGN Cross-sectional survey. SETTINGS South African primary public health facilities in 2012. PARTICIPANTS A national-level sample of 8618 pregnant women. OUTCOME MEASURES Wealth-related inequality in early uptake of HIV testing was measured using the Erreygers concentration index (CI) further adjusted for inequality introduced by predicted healthcare need (ie, need-standardised). Determinants contributing to the observed inequality were identified using the Erreygers and Wagstaff decomposition methods. RESULTS Participants were aged 13 to 49 years. Antenatal HIV prevalence was 33.2%, of which 43.7% came from the lowest 40% wealth group. A pro-poor wealth-related inequality in early HIV testing was observed. The need-standardised concentration index was -0.030 (95% confidence interval -0.038 to -0.022). The proportion of early HIV testing was significantly better in the lower 40% wealth group compared with the higher 40% wealth group (p value=0.040). The largest contributions to the observed inequality were from underlying inequalities in province (contribution, 65.27%), age (-44.38%), wealth group (24.73%) and transport means (21.61%). CONCLUSIONS Our results on better early uptake of HIV testing among the poorer subpopulation compared with the richer highlights inequity in uptake of HIV testing in South Africa. This socioeconomic difference could contribute to fast-tracking EMTCT given the high HIV prevalence among the lower wealth group. The high contribution of provinces and age to inequality highlights the need to shift from reliance on national-level estimates alone but identify subregional-specific and age-specific bottlenecks. Future interventions need to be context specific and tailored for specific subpopulations and subregional settings.
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Affiliation(s)
- Nobubelo Kwanele Ngandu
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Carine Van Malderen
- Institute of Health and Society (IRSS), Université catholique de Louvain, Brussels, Belgium
| | - Ameena Goga
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
- Department of Paediatrics and Child Health, Kalafong Hospital, University of Pretoria, Pretoria, South Africa
| | - Niko Speybroeck
- Institute of Health and Society (IRSS), Université catholique de Louvain, Brussels, Belgium
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"At our age, we would like to do things the way we want: " a qualitative study of adolescent HIV testing services in Kenya. AIDS 2017; 31 Suppl 3:S213-S220. [PMID: 28665879 PMCID: PMC5497781 DOI: 10.1097/qad.0000000000001513] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Supplemental Digital Content is available in the text Objectives: Adolescents in Africa have low HIV testing rates. Better understanding of adolescent, provider, and caregiver experiences in high-burden countries such as Kenya could improve adolescent HIV testing programs. Design: We conducted 16 qualitative interviews with HIV-positive and HIV-negative adolescents (13–18 years) and six focus group discussions with Healthcare workers (HCWs) and caregivers of adolescents in Nairobi, Kenya. Methods: Semi-structured interviews and focus groups were recorded and transcribed. Analysis employed a modified constant comparative approach to triangulate findings and identify themes influencing testing experiences and practices. Results: All groups identified that supportive interactions during testing were essential to the adolescent's positive testing experience. HCWs were a primary source of support during testing. HCWs who acted respectful and informed helped adolescents accept results, link to care, or return for repeat testing, whereas HCWs who acted dismissive or judgmental discouraged adolescent testing. Caregivers universally supported adolescent testing, including testing with the adolescent to demonstrate support. Caregivers relied on HCWs to inform and encourage adolescents. Although peers played less significant roles during testing, all groups agreed that school-based outreach could increase peer demand and counteract stigma. All groups recognized tensions around adolescent autonomy in the absence of clear consent guidelines. Adolescents valued support people during testing but wanted autonomy over testing and disclosure decisions. HCWs felt pressured to defer consent to caregivers. Caregivers wanted to know results regardless of adolescents’ wishes. Conclusion: Findings indicate that strengthening HCW, caregiver, and peer capacities to support adolescents while respecting their autonomy may facilitate attaining ‘90-90-90’ targets for adolescents.
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Karwa R, Maina M, Mercer T, Njuguna B, Wachira J, Ngetich C, Some F, Jakait B, Owino RK, Gardner A, Pastakia S. Leveraging peer-based support to facilitate HIV care in Kenya. PLoS Med 2017; 14:e1002355. [PMID: 28708845 PMCID: PMC5510806 DOI: 10.1371/journal.pmed.1002355] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Rakhi Karwa and colleagues discuss a program in which peer navigators support care for people with HIV at a Kenyan hospital.
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Affiliation(s)
- Rakhi Karwa
- College of Pharmacy, Purdue University, West Lafayette, Indiana, United States of America
- College of Health Sciences, Moi University, Eldoret, Kenya
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
- * E-mail:
| | - Mercy Maina
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
- Moi Teaching and Referral Hospital, Eldoret, Kenya
| | - Timothy Mercer
- College of Health Sciences, Moi University, Eldoret, Kenya
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
- Indiana University School of Medicine, Indianapolis, Indiana, United States of America
| | | | - Juddy Wachira
- College of Health Sciences, Moi University, Eldoret, Kenya
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | - Celia Ngetich
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
- Moi Teaching and Referral Hospital, Eldoret, Kenya
| | - Fatma Some
- College of Health Sciences, Moi University, Eldoret, Kenya
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | - Beatrice Jakait
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
- Moi Teaching and Referral Hospital, Eldoret, Kenya
| | - Regina K. Owino
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
- Moi Teaching and Referral Hospital, Eldoret, Kenya
| | - Adrian Gardner
- College of Health Sciences, Moi University, Eldoret, Kenya
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
- Indiana University School of Medicine, Indianapolis, Indiana, United States of America
| | - Sonak Pastakia
- College of Pharmacy, Purdue University, West Lafayette, Indiana, United States of America
- College of Health Sciences, Moi University, Eldoret, Kenya
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
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