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Larson BA, Tsikhutsu I, Bii M, Halim N, Agaba P, Sugut W, Muli J, Sawe F. The effects of revised peer-counselor support on the PMTCT cascade of care: results from a cluster-randomized trial in Kenya (the EMMA study). BMC Infect Dis 2023; 23:257. [PMID: 37098468 PMCID: PMC10127503 DOI: 10.1186/s12879-023-08246-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 04/12/2023] [Indexed: 04/27/2023] Open
Abstract
BACKGROUND This study evaluated the effect of revisions to existing peer-counselor services, called Mentor Mothers (MM), at maternal and child health clinics on medication adherence for women living with HIV (WLWH) in Kenya and on early infant HIV testing. METHODS The Enhanced Mentor Mother Program study was a 12-site, two-arm cluster-randomized trial enrolling pregnant WLWH from March 2017 to June 2018 (with data collection through September 2020). Six clinics were randomized to continued MM-supported standard care (SC). Six clinics were randomized to the intervention arm (INT = SC plus revised MM services to include more one-on-one interactions). Primary outcomes for mothers were defined as: (PO1) the proportion of days covered (PDC) with antiretroviral therapy (ART) ≥ 0.90 during the last 24-weeks of pregnancy; and (PO2) ≥ 0.90 PDC during the first 24-weeks postpartum. Secondary outcomes were infant HIV testing according to national guidelines (at 6, 24, and 48 weeks). Crude and adjusted risk differences between study arms are reported. RESULTS We enrolled 363 pregnant WLHV. After excluding known transfers and subjects with incomplete data extraction, data were analyzed for 309 WLWH (151 SC, 158 INT). A small share achieved high PDC during the prenatal and postnatal periods (0.33 SC/0.24 INT achieved PO1; 0.30 SC/0.31 INT achieved PO2; crude or adjusted risk differences were not statistically significant). In addition, ~ 75% in both study arms completed viral load testing during year two after enrollment, with > 90% suppressed in both arms. For infants, ≥ 90% in both arms had at least one HIV test through study follow up (76 weeks) but testing on schedule according to PMTCT guidelines was uncommon. CONCLUSIONS While national guidelines in Kenya recommended that all HIV-infected pregnant women take a daily antiretroviral regimen for life following a HIV diagnosis, results presented here indicate that a minor share achieved high medication coverage during the prenatal and postnatal periods analyzed. In addition, adjustments to Mentor-Mother services showed no improvement in study outcomes. The lack of effect for this behavioral intervention is relatively consistent with the existing literature to improve mother-infant outcomes along the PMTCT care cascade. CLINICAL TRIAL NUMBER NCT02848235. Date of first trial registration 28/07/2016.
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Affiliation(s)
- Bruce A Larson
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Boston, MA, 02118, USA.
| | - Isaac Tsikhutsu
- Kenya Medical Research Institute, Kericho, Kenya/U.S. Army Medical Research Directorate-Africa, Nairobi, Kenya
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
- HJF Medical Research International, Kericho, Kenya
| | - Margaret Bii
- Kenya Medical Research Institute, Kericho, Kenya/U.S. Army Medical Research Directorate-Africa, Nairobi, Kenya
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
- HJF Medical Research International, Kericho, Kenya
| | - Nafisa Halim
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Boston, MA, 02118, USA
| | - Patricia Agaba
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - William Sugut
- Kenya Medical Research Institute, Kericho, Kenya/U.S. Army Medical Research Directorate-Africa, Nairobi, Kenya
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
- HJF Medical Research International, Kericho, Kenya
| | - Jane Muli
- Kenya Medical Research Institute, Kericho, Kenya/U.S. Army Medical Research Directorate-Africa, Nairobi, Kenya
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
- HJF Medical Research International, Kericho, Kenya
| | - Fredrick Sawe
- Kenya Medical Research Institute, Kericho, Kenya/U.S. Army Medical Research Directorate-Africa, Nairobi, Kenya
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
- HJF Medical Research International, Kericho, Kenya
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Ibu JM, Mhlongo EM. The Mentor-Mothers program in the Nigeria Department of Defense: policies, processes, and implementation. BMC Health Serv Res 2022; 22:988. [PMID: 35922797 PMCID: PMC9347106 DOI: 10.1186/s12913-022-08382-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Accepted: 07/25/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Nigeria has the second largest HIV epidemic in the world and is one of the countries with the highest rates of new pediatric infections in sub-Saharan Africa. The country faces several challenges in the provision of healthcare services and coverage of Prevention of Mother to child transmission of HIV. In the Nigeria's Department of Defense, prevention of vertically transmitted HIV infections has been given a boost by utilizing Mentor Mothers to facilitate antiretroviral compliance and retention in care. The aim of this study was to explore those processes and policies that guide the implementation of the Mentor Mothers program for PMTCT of HIV in the Department of Defense in Nigeria as no studies have examined this so far. METHODS The descriptive, qualitative research approach was utilized. We conducted 7 key informants interviews with 7 purposively selected participants made up of 2 program Directors, 1 Doctor, 1 PMTCT focal Nurse, 1 PMTCT site coordinator, 1 Mentor Mother, and 1 patient from one each of the health facilities of the Army, Navy, Airforce and the Defence Headquarters Medical Centre. Open coding for major themes and sub-themes was done. Data were analyzed using thematic analysis. RESULTS Findings revealed that the program in the Department of Defense had been modelled after the WHO and implementing partners' guidelines. Foundational Factors; Leadership; Skill acquisition; and Service Characteristics emerged as processes guiding the implementation of the Mentor-Mothers program in the DoD. These findings supported the Mentor Mother Model, which empowers mothers living with HIV - through education and employment - to promote access to essential PMTCT services and medical care to HIV positive pregnant women. CONCLUSION We concluded that no definitive policy establishes the Mentor Mothers program in the DoD. Working with Doctors, Nurses, local & collaborating partners, and communities in which these hospitals are located, the Mentor Mothers play a pivotal role in the formation, facilitation, and implementation of the MM model to effectively decrease HIV infections in children and reduce child and maternal mortality in women and families they interact with.
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Affiliation(s)
- Josephine Moshe Ibu
- Discipline of Nursing, School of Nursing and Public Health, University of KwaZulu-Natal, Private Bag X5400, DurbanDurban, 4000, South Africa.
| | - Euphemia Mbali Mhlongo
- Discipline of Nursing, School of Nursing and Public Health, University of KwaZulu-Natal, Private Bag X5400, DurbanDurban, 4000, South Africa
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Lee EH, Ganesan K, Khamadi SA, Meribe SC, Njeru D, Adamu Y, Magala F, Crowell TA, Akom E, Agaba P, Desai P, Hamm T, Teyhen D, Ake JA, Polyak CS, Shaffer D, Sawe F, Hickey PW. Attaining 95-95-95 through Implementation Science: 15 Years of Insights and Best Practices from the Walter Reed Army Institute of Research's Implementation of the U.S. President's Emergency Plan for AIDS Relief. Am J Trop Med Hyg 2021; 104:12-25. [PMID: 33241783 PMCID: PMC7790083 DOI: 10.4269/ajtmh.20-0541] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
The Walter Reed Army Institute of Research (WRAIR) supports more than 350,000 people on lifesaving HIV treatment in Kenya, Nigeria, Tanzania, and Uganda through funding from the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR). Here, we review and synthesize the range of impacts WRAIR’s implementation science portfolio has had on PEPFAR service delivery for military and civilian populations since 2003. We also explore how investments in implementation science create institutional synergies within the U.S. Department of Defense, contributing to broad global health engagements and improving health outcomes for populations served. Finally, we discuss WRAIR’s contributions to PEPFAR priorities through use of data to drive and improve programming in real time in the era of HIV epidemic control and public health messaging that includes prevention, the 95-95-95 goals, and comorbidities.
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Affiliation(s)
- Elizabeth H Lee
- 1U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland.,2The Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Kavitha Ganesan
- 1U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland.,3Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland
| | - Samoel A Khamadi
- 1U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland.,4HJF Medical Research International, Mbeya, Tanzania
| | | | - Dorothy Njeru
- 6U.S. Army Medical Research Directorate-Africa, Nairobi, Kenya
| | - Yakubu Adamu
- 5U.S. Army Medical Research Directorate-Africa, Abuja, Nigeria
| | - Fred Magala
- 7Makerere University Walter Reed Project, Kampala, Uganda
| | - Trevor A Crowell
- 1U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland.,2The Uniformed Services University of the Health Sciences, Bethesda, Maryland.,3Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland
| | - Eniko Akom
- 1U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland.,3Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland
| | - Patricia Agaba
- 1U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland.,3Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland
| | - Priyanka Desai
- 1U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland.,3Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland
| | - Tiffany Hamm
- 1U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland.,3Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland
| | - Deydre Teyhen
- 1U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland
| | - Julie A Ake
- 1U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland
| | - Christina S Polyak
- 1U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland.,3Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland
| | - Douglas Shaffer
- 8U.S. Department of Health and Human Services, Nairobi, Kenya
| | - Fredrick Sawe
- 6U.S. Army Medical Research Directorate-Africa, Nairobi, Kenya.,9HJF Medical Research International, Kericho, Kenya
| | - Patrick W Hickey
- 2The Uniformed Services University of the Health Sciences, Bethesda, Maryland
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Matthews LT, Orrell C, Bwana MB, Tsai AC, Psaros C, Asiimwe S, Amanyire G, Musinguzi N, Bell K, Bangsberg DR, Haberer JE. Adherence to HIV antiretroviral therapy among pregnant and postpartum women during the Option B+ era: 12-month cohort study in urban South Africa and rural Uganda. J Int AIDS Soc 2020; 23:e25586. [PMID: 32820622 PMCID: PMC7441010 DOI: 10.1002/jia2.25586] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 06/18/2020] [Accepted: 07/01/2020] [Indexed: 01/18/2023] Open
Abstract
INTRODUCTION We conducted a cohort study to understand patterns of anti-retroviral therapy (ART) adherence during pregnancy, postpartum and non-pregnancy follow-up among women initiating ART in public clinics offering Option B+ in rural Uganda and urban South Africa. METHODS We collected survey data, continuously monitored ART adherence (Wisepill), HIV-RNA and pregnancy tests at zero, six and twelve months from women initiating ART in Uganda and South Africa, 2015 to 2017. The primary predictor of interest was follow-up time categorized as pregnant (pregnancy diagnosis to pregnancy end), postpartum (pregnancy end to study exit) or non-pregnancy-related (neither pregnant nor postpartum). Fractional regression models included demographics and socio-behavioural factors informed by the Behavioral Model for Vulnerable Populations. We evaluated HIV-RNA at 12 months by ever- versus never-pregnant status. RESULTS In Uganda, 247 women contributed 676, 900 and 1274 months of pregnancy, postpartum and non-pregnancy-related follow-up. Median ART adherence was consistently ≥90%: pregnancy, 94% (interquartile range [IQR] 78,98); postpartum, 90% (IQR 70,97) and non-pregnancy, 90% (IQR 80,98). Poorer adherence was associated with younger age (0.98% [95% CI 0.33%, 1.62%] average increase per year of age) and higher CD4 cell count (1.01% [0.08%, 1.94%] average decrease per 50 cells/mm3 ). HIV-RNA was suppressed among 91% (N = 135) ever-pregnant and 86% (N = 85) never-pregnant women. In South Africa, 190 women contributed 259, 624 and 1247 months of pregnancy, postpartum and non-pregnancy-related follow-up. Median adherence was low during pregnancy, 74% (IQR 31,96); postpartum, 40% (IQR 4,65) and non-pregnancy, 77% (IQR 47,92). Poorer adherence was associated with postpartum status (22.3% [95%CI 8.6%, 35.4%] average decrease compared to non-pregnancy-related follow-up) and less emotional support (1.4% [0.22%, 2.58%] average increase per unit increase). HIV-RNA was suppressed among 57% (N = 47) ever-pregnant and 86% (N = 93) never-pregnant women. CONCLUSIONS Women in rural Uganda maintained high adherence with 91% of ever-pregnant and 86% of never-pregnant women suppressing HIV-RNA at 12 months. Women in urban South Africa struggled with adherence, particularly during postpartum follow-up with median adherence of 40% and 57% of women with HIV-RNA suppression at one year, suggesting a crisis for postpartum women with HIV in South Africa. Findings suggest that effective interventions should promote emotional support.
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Affiliation(s)
- Lynn T Matthews
- Department of MedicineUniversity of Alabama at BirminghamBirminghamALUSA
- Department of MedicineMassachusetts General HospitalBostonMAUSA
| | | | | | - Alexander C Tsai
- Mbarara University of Science and TechnologyMbararaUganda
- Center for Global HealthMassachusetts General HospitalBostonMAUSA
- Harvard Center for Population and Development StudiesBostonMAUSA
| | - Christina Psaros
- Department of PsychiatryMassachusetts General HospitalBostonMAUSA
| | - Stephen Asiimwe
- Mbarara University of Science and TechnologyMbararaUganda
- Center for Global HealthMassachusetts General HospitalBostonMAUSA
- Kabwohe Clinical Research Center (KCRC)KabwoheUganda
| | - Gideon Amanyire
- Makerere‐Mbarara Universities Joint AIDS Program (MJAP)MbararaUganda
| | - Nicholas Musinguzi
- Mbarara University of Science and TechnologyMbararaUganda
- Center for Global HealthMassachusetts General HospitalBostonMAUSA
| | - Kathleen Bell
- Center for Global HealthMassachusetts General HospitalBostonMAUSA
| | - David R Bangsberg
- School of Public HealthOregon Health and Science University/Portland State UniversityPortlandORUSA
| | - Jessica E Haberer
- Department of MedicineMassachusetts General HospitalBostonMAUSA
- Center for Global HealthMassachusetts General HospitalBostonMAUSA
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Larson BA, Halim N, Tsikhutsu I, Bii M, Coakley P, Rockers PC. A tool for estimating antiretroviral medication coverage for HIV-infected women during pregnancy (PMTCT-ACT). Glob Health Res Policy 2019; 4:29. [PMID: 31637308 PMCID: PMC6794749 DOI: 10.1186/s41256-019-0121-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 09/23/2019] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND In the typical prevention of mother to child transmission (PMTCT) of HIV cascade of care discussion or analysis, the period of analysis begins at the first visit for antenatal care (ANC) for that pregnancy. This starting point is problematic for two reasons: (1) a large number of HIV-infected women are already on life-long antiretroviral therapy (ART) when presenting for ANC; and (2) women present to ANC at different gestational ages. The PMTCT ART Coverage Tool (PMTCT-ACT), which estimates the proportion of days covered (PDC) with ART, was developed to address each of these problems. METHODS PDC is a preferred method to measure adherence to chronic medications, such as ART. For evaluating the PMTCT cascade of care, as indicated by PDC with ART over various time periods, a "starting point" based on a specific day before delivery must be defined that applies to all women (treatment experienced or naïve at the first ANC visit at any gestational age). Using the example of 168 days prior to delivery (24 weeks), PMTCT-ACT measures PDC with ART during that period. PMTCT-ACT is provided as a STATA do-file. Using an example dataset for two women (ID1 is treatment experienced; ID2 is treatment naïve), the details of each major portion of the tool (Parts 1-5) are presented. PMTCT-ACT along with the intermediate datasets created during the analysis are provided as supplemental files. CONCLUSIONS Evaluating the PMTCT cascade of care requires a standard definition of the follow-up period during pregnancy that applies to all HIV-infected pregnant women and a standard measure of adherence. PMTCT-ACT is a new tool that fits this purpose. PMTCT-ACT can also be easily adjusted to evaluate other ante- and post-natal periods (e.g., final 4 weeks, final 8 weeks, complete pregnancy period, initial 24 weeks postpartum, time periods consistent with infant HIV testing guidelines).
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Affiliation(s)
- Bruce A. Larson
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Boston, MA 02118 USA
| | - Nafisa Halim
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Boston, MA 02118 USA
| | - Isaac Tsikhutsu
- Kenya Medical Research Institute, U.S. Army Medical Research Directorate, Africa, Kenya
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD USA
- Henry Jackson Foundation MRI, Kericho, Kenya
| | - Margaret Bii
- Kenya Medical Research Institute, U.S. Army Medical Research Directorate, Africa, Kenya
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD USA
- Henry Jackson Foundation MRI, Kericho, Kenya
| | - Peter Coakley
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD USA
| | - Peter C. Rockers
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Boston, MA 02118 USA
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