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Sambayi GL, Bwire GM, Kilapilo MS, Myemba DT, Mosha IH, Kilonzi M, Magati RB, Amour M, Mwakalukwa R, Mangara AN, Bakari M, Sudfeld CR, Matee MIN, Sangeda RZ, Adams LV, Killewo J. Barriers and Enablers to Retention in HIV Care and Adherence to Antiretroviral Therapy: Evidence from Dar es Salaam, Tanzania. HIV AIDS (Auckl) 2024; 16:301-311. [PMID: 39081498 PMCID: PMC11288357 DOI: 10.2147/hiv.s458545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 05/21/2024] [Indexed: 08/02/2024] Open
Abstract
Purpose To explore the enabling factors, barriers, and strategies to improve retention in HIV care and adherence to antiretroviral therapy (ART) among adults (18 years and above) living with HIV in Dar es Salaam, Tanzania. Methods We conducted a descriptive qualitative study to better understand and explore enablers, barriers, and strategies to improve retention in HIV care and adherence to antiretroviral therapy (ART) among PLHIV in Dar es Salaam, Tanzania. Focus group discussions (FGD) were conducted with a semi-structured discussion guide between December 2021 and June 2022. A non-random purposive sampling technique was used to select PLHIV and people involved in provision of healthcare and socioeconomic support to PLHIV. Thematic analysis was used to identify and interpret the themes. Results Three major themes with 10 sub-themes emerged. Participants indicated that family and partner support, peer-support group/adherence clubs, and healthcare provider counselling on medication adherence facilitated retention and adherence to ART. In contrast, stigma and discrimination, financial constraints, disease outbreaks such as the COVID-19 pandemic, myths and misconceptions about HIV, and side effects of antiretrovirals were mentioned as barriers. Strengthening community and patient education about HIV and ART through peer support groups and financial support for poor PLHIV were the proposed mitigation. Conclusion Addressing the challenges to ART adherence may require a more holistic approach. We recommend the implementation of peer support groups and financial support through small microfinance groups as interventions to increase retention in HIV care and adherence to ART in the study area.
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Affiliation(s)
- Godfrey L Sambayi
- Department of Pharmacognosy, School of Pharmacy, Muhimbili University of Health and Allied Sciences, Dar es Salaam, 65013, Tanzania
| | - George M Bwire
- Department of Microbiology, Immunology and Transplantation, Rega Institute for Medical Research Clinical and Epidemiological Virology, Institute for the Future, KU Leuven, Leuven, 3000, Belgium
- Department of Pharmaceutical Microbiology, School of Pharmacy, Muhimbili University of Health and Allied Sciences, Dar es Salaam, 65013, Tanzania
| | - Mary Spicar Kilapilo
- Department of Pharmaceutical Microbiology, School of Pharmacy, Muhimbili University of Health and Allied Sciences, Dar es Salaam, 65013, Tanzania
| | - David T Myemba
- Department of Pharmaceutics and Pharmacy Practice, School of Pharmacy, Muhimbili University of Health and Allied Sciences, Dar es Salaam, 65013, Tanzania
| | - Idda H Mosha
- Department of Behavioural Sciences, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, 65015, Tanzania
| | - Manase Kilonzi
- Department of Clinical Pharmacy and Pharmacology, School of Pharmacy, Muhimbili University of Health and Allied Sciences, Dar es Salaam, 65013, Tanzania
| | - Renatus B Magati
- Department of Clinical Nursing, Catholic University of Health and Allied Sciences, Mwanza, P.O. Box 1464, Tanzania
| | - Maryam Amour
- Department of Community Health, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, 65015, Tanzania
| | - Rogers Mwakalukwa
- Department of Pharmacognosy, School of Pharmacy, Muhimbili University of Health and Allied Sciences, Dar es Salaam, 65013, Tanzania
| | - Ally Nassoro Mangara
- Dar Es Salaam Urban Cohort Study, Department of Epidemiology and Biostatistics, School of Public Health and Social Sciences, Dar es Salaam, 65013, Tanzania
| | - Muhammad Bakari
- Department of Internal Medicine, School of Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, P.O. Box 65001, Tanzania
| | - Christopher R Sudfeld
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Mecky I N Matee
- Department of Microbiology and Immunology, School of Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, 65013, Tanzania
| | - Raphael Z Sangeda
- Department of Pharmaceutical Microbiology, School of Pharmacy, Muhimbili University of Health and Allied Sciences, Dar es Salaam, 65013, Tanzania
| | - Lisa V Adams
- Department of Medicine, Center for Global Health Equity, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Japhet Killewo
- Department of Epidemiology and Biostatistics, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, 65015, Tanzania
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Pinto PFPS, Macinko J, Silva AF, Lua I, Jesus G, Magno L, Santos CAST, Ichihara MY, Barreto ML, Moucheraud C, Souza LE, Dourado I, Rasella D. The impact of primary health care on AIDS incidence and mortality: A cohort study of 3.4 million Brazilians. PLoS Med 2024; 21:e1004302. [PMID: 38991004 PMCID: PMC11272382 DOI: 10.1371/journal.pmed.1004302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Revised: 07/25/2024] [Accepted: 05/22/2024] [Indexed: 07/13/2024] Open
Abstract
BACKGROUND Primary Health Care (PHC) is essential for effective, efficient, and more equitable health systems for all people, including those living with HIV/AIDS. This study evaluated the impact of the exposure to one of the largest community-based PHC programs in the world, the Brazilian Family Health Strategy (FHS), on AIDS incidence and mortality. METHODS AND FINDINGS A retrospective cohort study carried out in Brazil from January 1, 2007 to December 31, 2015. We conducted an impact evaluation using a cohort of 3,435,068 ≥13 years low-income individuals who were members of the 100 Million Brazilians Cohort, linked to AIDS diagnoses and deaths registries. We evaluated the impact of FHS on AIDS incidence and mortality and compared outcomes between residents of municipalities with low or no FHS coverage (unexposed) with those in municipalities with 100% FHS coverage (exposed). We used multivariable Poisson regressions adjusted for all relevant municipal and individual-level demographic, socioeconomic, and contextual variables, and weighted with inverse probability of treatment weighting (IPTW). We also estimated the FHS impact by sex and age and performed a wide range of sensitivity and triangulation analyses; 100% FHS coverage was associated with lower AIDS incidence (rate ratio [RR]: 0.76, 95% CI: 0.68 to 0.84) and mortality (RR: 0.68, 95%CI: 0.56 to 0.82). FHS impact was similar between men and women, but was larger in people aged ≥35 years old both for incidence (RR: 0.62, 95% CI: 0.53 to 0.72) and mortality (RR: 0.56, 95% CI: 0.43 to 0.72). The absence of important confounding variables (e.g., sexual behavior) is a key limitation of this study. CONCLUSIONS AIDS should be an avoidable outcome for most people living with HIV today and our study shows that FHS coverage could significantly reduce AIDS incidence and mortality among low-income populations in Brazil. Universal access to comprehensive healthcare through community-based PHC programs should be promoted to achieve the Sustainable Development Goals of ending AIDS by 2030.
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Affiliation(s)
- Priscila F. P. S. Pinto
- Institute of Collective Health, Federal University of Bahia (ISC/UFBA), Salvador, Brazil
- The Centre for Data and Knowledge Integration for Health (CIDACS-Fiocruz), Salvador, Brazil
| | - James Macinko
- Departments of Health Policy and Management and Community Health Sciences, Fielding School of Public Health, University of California (UCLA), Los Angeles, California, United States of America
| | - Andréa F. Silva
- Institute of Collective Health, Federal University of Bahia (ISC/UFBA), Salvador, Brazil
- The Centre for Data and Knowledge Integration for Health (CIDACS-Fiocruz), Salvador, Brazil
| | - Iracema Lua
- Institute of Collective Health, Federal University of Bahia (ISC/UFBA), Salvador, Brazil
- The Centre for Data and Knowledge Integration for Health (CIDACS-Fiocruz), Salvador, Brazil
| | - Gabriela Jesus
- Institute of Collective Health, Federal University of Bahia (ISC/UFBA), Salvador, Brazil
- The Centre for Data and Knowledge Integration for Health (CIDACS-Fiocruz), Salvador, Brazil
| | - Laio Magno
- Department of Life Sciences, State University of Bahia (UNEB), Salvador, Brazil
| | | | - Maria Yury Ichihara
- The Centre for Data and Knowledge Integration for Health (CIDACS-Fiocruz), Salvador, Brazil
| | - Mauricio L. Barreto
- The Centre for Data and Knowledge Integration for Health (CIDACS-Fiocruz), Salvador, Brazil
| | - Corrina Moucheraud
- Departments of Health Policy and Management and Community Health Sciences, Fielding School of Public Health, University of California (UCLA), Los Angeles, California, United States of America
| | - Luis E. Souza
- Institute of Collective Health, Federal University of Bahia (ISC/UFBA), Salvador, Brazil
| | - Inês Dourado
- Institute of Collective Health, Federal University of Bahia (ISC/UFBA), Salvador, Brazil
| | - Davide Rasella
- Institute of Collective Health, Federal University of Bahia (ISC/UFBA), Salvador, Brazil
- Instituto de Salud Global Barcelona (ISGlobal), Hospital Clínic—Universitat de Barcelona, Barcelona, Spain
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Gumede SB, de Wit JBF, Venter WDF, Wensing AMJ, Lalla‐Edward ST. Intervention strategies to improve adherence to treatment for selected chronic conditions in sub-Saharan Africa: a systematic review. J Int AIDS Soc 2024; 27:e26266. [PMID: 38924296 PMCID: PMC11197966 DOI: 10.1002/jia2.26266] [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: 09/03/2023] [Accepted: 04/23/2024] [Indexed: 06/28/2024] Open
Abstract
INTRODUCTION Evidence-based intervention strategies to improve adherence among individuals living with chronic conditions are critical in ensuring better outcomes. In this systematic review, we assessed the impact of interventions that aimed to promote adherence to treatment for chronic conditions. METHODS We systematically searched PubMed, Web of Science, Scopus, Google Scholar and CINAHL databases to identify relevant studies published between the years 2000 and 2023 and used the QUIPS assessment tool to assess the quality and risk of bias of each study. We extracted data from eligible studies for study characteristics and description of interventions for the study populations of interest. RESULTS Of the 32,698 total studies/records screened, 2814 were eligible for abstract screening and of those, 497 were eligible for full-text screening. A total of 82 studies were subsequently included, describing a total of 58,043 patients. Of the total included studies, 58 (70.7%) were related to antiretroviral therapy for HIV, 6 (7.3%) were anti-hypertensive medication-related, 12 (14.6%) were anti-diabetic medication-related and 6 (7.3%) focused on medication for more than one condition. A total of 54/82 (65.9%) reported improved adherence based on the described study outcomes, 13/82 (15.9%) did not have clear results or defined outcomes, while 15/82 (18.3%) reported no significant difference between studied groups. The 82 publications described 98 unique interventions (some studies described more than one intervention). Among these intervention strategies, 13 (13.3%) were multifaceted (4/13 [30.8%] multi-component health services- and community-based programmes, 6/13 [46.2%] included individual plus group counselling and 3/13 [23.1%] included SMS or alarm reminders plus individual counselling). DISCUSSION The interventions described in this review ranged from adherence counselling to more complex interventions such as mobile health (mhealth) interventions. Combined interventions comprised of different components may be more effective than using a single component in isolation. However, the complexity involved in designing and implementing combined interventions often complicates the practicalities of such interventions. CONCLUSIONS There is substantial evidence that community- and home-based interventions, digital health interventions and adherence counselling interventions can improve adherence to medication for chronic conditions. Future research should answer if existing interventions can be used to develop less complicated multifaceted adherence intervention strategies.
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Affiliation(s)
- Siphamandla Bonga Gumede
- Ezintsha, Faculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
- Department of Interdisciplinary Social ScienceUtrecht UniversityUtrechtthe Netherlands
| | - John B. F. de Wit
- Department of Interdisciplinary Social ScienceUtrecht UniversityUtrechtthe Netherlands
- Centre for Social Research in HealthUNSWSydneyNew South WalesAustralia
| | - Willem D. F. Venter
- Ezintsha, Faculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Annemarie M. J. Wensing
- Department of Medical MicrobiologyUniversity Medical Center UtrechtUtrechtthe Netherlands
- Ndlovu Research ConsortiumElandsdoornSouth Africa
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Jiang W, Ronen K, Osborn L, Drake AL, Unger JA, Matemo D, Richardson BA, Kinuthia J, John-Stewart G. HIV Viral Load Patterns and Risk Factors Among Women in Prevention of Mother-To-Child Transmission Programs to Inform Differentiated Service Delivery. J Acquir Immune Defic Syndr 2024; 95:246-254. [PMID: 37977207 PMCID: PMC10922247 DOI: 10.1097/qai.0000000000003352] [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: 06/24/2023] [Accepted: 11/06/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND Differentiated service delivery (DSD) approaches decrease frequency of clinic visits for individuals who are stable on antiretroviral therapy. It is unclear how to optimize DSD models for postpartum women living with HIV (PWLH). We evaluated longitudinal HIV viral load (VL) and cofactors, and modelled DSD eligibility with virologic failure (VF) among PWLH in prevention of mother-to-child transmission programs. METHODS This analysis used programmatic data from participants in the Mobile WAChX trial (NCT02400671). Women were assessed for DSD eligibility using the World Health Organization criteria among general people living with HIV (receiving antiretroviral therapy for ≥6 months and having at least 1 suppressed VL [<1000 copies/mL] within the past 6 months). Longitudinal VL patterns were summarized using group-based trajectory modelling. VF was defined as having a subsequent VL ≥1000 copies/mL after being assessed as DSD-eligible. Predictors of VF were determined using log-binomial models among DSD-eligible PWLH. RESULTS Among 761 women with 3359 VL results (median 5 VL per woman), a 3-trajectory model optimally summarized longitudinal VL, with most (80.8%) women having sustained low probability of unsuppressed VL. Among women who met DSD criteria at 6 months postpartum, most (83.8%) maintained viral suppression until 24 months. Residence in Western Kenya, depression, reported interpersonal abuse, unintended pregnancy, nevirapine-based antiretroviral therapy, low-level viremia (VL 200-1000 copies/mL), and drug resistance were associated with VF among DSD-eligible PWLH. CONCLUSIONS Most postpartum women maintained viral suppression from early postpartum to 24 months and may be suitable for DSD referral. Women with depression, drug resistance, and detectable VL need enhanced services.
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Affiliation(s)
- Wenwen Jiang
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | - Keshet Ronen
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Lusi Osborn
- Department of Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Alison L. Drake
- Global Health, University of Washington, Seattle, Washington, USA
| | - Jennifer A. Unger
- Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA, Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Daniel Matemo
- Department of Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Barbra A. Richardson
- Departments of Biostatistics and Global Health, University of Washington, Division of Vaccine and Infectious Disease, Fred Hutchinson Cancer Center, Seattle, Washington, USA
| | - John Kinuthia
- Department of Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Grace John-Stewart
- Departments of Global Health, Medicine, Pediatrics, and Epidemiology, University of Washington, Seattle, Washington, USA
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Raeber F, Haldemann MI, Ray S, Huber J, Firima E, Fernandez LG, Amstutz A, Gerber F, Labhardt ND, Belus JM. Community-based models of care for adolescent and adult depression, suicidal behavior, anxiety, trauma, and substance use in Africa: a scoping review. Front Psychol 2024; 15:1241403. [PMID: 38406302 PMCID: PMC10885163 DOI: 10.3389/fpsyg.2024.1241403] [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: 06/16/2023] [Accepted: 01/22/2024] [Indexed: 02/27/2024] Open
Abstract
Background Community-based care (CBC), where care is delivered outside of the traditional health facility setting, has been proposed to narrow the mental health (MH) and substance use (SU) treatment gap in Africa. Objective This scoping review aims to comprehensively summarize CBC models addressing adolescent and adult MH (depression, anxiety, trauma, suicidal behavior) and (non-tobacco) SU problems in Africa. Methods We searched PsycINFO, Embase, Scopus, CINAHL, and Medline Ovid. Studies and protocols were included if they reported on CBC intervention's effects on MH or SU symptoms/ diagnoses, acceptability, feasibility, or patient engagement in care, regardless of whether the intervention itself was designed specifically for MH or SU. Results Among 11,477 screened publications, 217 were eligible. Of the unique intervention studies (n = 206), CBC models were classified into the following approaches (non-mutually exclusive): psychotherapeutic (n = 144), social (n = 81), lifestyle/physical health (n = 55), economic (n = 26), and psychopharmacological (n = 2). While quantitative results suggest possible efficacy of CBC models, description of CBC location was often poor. Fewer interventions addressed suicidal behavior (n = 12), the needs of adolescents (n = 49), or used traditional healers or religious figures as providers (n = 3). Conclusion Many CBC models have been tested on MH and SU in Africa and should be critically appraised and meta-analyzed in subsequent reviews, where possible.
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Affiliation(s)
- Fabian Raeber
- Division of Clinical Epidemiology, Department of Clinical Research, University and University Hospital Basel, Basel, Switzerland
| | - Maria-Inés Haldemann
- Division of Clinical Epidemiology, Department of Clinical Research, University and University Hospital Basel, Basel, Switzerland
| | - Somidha Ray
- Research Consultant, International Center for Research on Women, New Delhi, India
| | - Jacqueline Huber
- Swiss TPH Library, Swiss Tropical and Public Health Institute, Allschwil, Basel, Switzerland
| | - Emmanuel Firima
- Division of Clinical Epidemiology, Department of Clinical Research, University and University Hospital Basel, Basel, Switzerland
- Department of Medicine, Swiss Tropical and Public Health Institute, Allschwil, Switzerland
| | - Lucia Gonzalez Fernandez
- Division of Clinical Epidemiology, Department of Clinical Research, University and University Hospital Basel, Basel, Switzerland
- Department of Medicine, Swiss Tropical and Public Health Institute, Allschwil, Switzerland
| | - Alain Amstutz
- Division of Clinical Epidemiology, Department of Clinical Research, University and University Hospital Basel, Basel, Switzerland
| | - Felix Gerber
- Division of Clinical Epidemiology, Department of Clinical Research, University and University Hospital Basel, Basel, Switzerland
- Department of Medicine, Swiss Tropical and Public Health Institute, Allschwil, Switzerland
| | - Niklaus D. Labhardt
- Division of Clinical Epidemiology, Department of Clinical Research, University and University Hospital Basel, Basel, Switzerland
| | - Jennifer M. Belus
- Division of Clinical Epidemiology, Department of Clinical Research, University and University Hospital Basel, Basel, Switzerland
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Mody A, Sohn AH, Iwuji C, Tan RKJ, Venter F, Geng EH. HIV epidemiology, prevention, treatment, and implementation strategies for public health. Lancet 2024; 403:471-492. [PMID: 38043552 DOI: 10.1016/s0140-6736(23)01381-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 05/28/2023] [Accepted: 06/29/2023] [Indexed: 12/05/2023]
Abstract
The global HIV response has made tremendous progress but is entering a new phase with additional challenges. Scientific innovations have led to multiple safe, effective, and durable options for treatment and prevention, and long-acting formulations for 2-monthly and 6-monthly dosing are becoming available with even longer dosing intervals possible on the horizon. The scientific agenda for HIV cure and remission strategies is moving forward but faces uncertain thresholds for success and acceptability. Nonetheless, innovations in prevention and treatment have often failed to reach large segments of the global population (eg, key and marginalised populations), and these major disparities in access and uptake at multiple levels have caused progress to fall short of their potential to affect public health. Moving forward, sharper epidemiologic tools based on longitudinal, person-centred data are needed to more accurately characterise remaining gaps and guide continued progress against the HIV epidemic. We should also increase prioritisation of strategies that address socio-behavioural challenges and can lead to effective and equitable implementation of existing interventions with high levels of quality that better match individual needs. We review HIV epidemiologic trends; advances in HIV prevention, treatment, and care delivery; and discuss emerging challenges for ending the HIV epidemic over the next decade that are relevant for general practitioners and others involved in HIV care.
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Affiliation(s)
- Aaloke Mody
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO, USA.
| | - Annette H Sohn
- TREAT Asia, amfAR, The Foundation for AIDS Research, Bangkok, Thailand
| | - Collins Iwuji
- Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Brighton, UK; Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - Rayner K J Tan
- University of North Carolina Project-China, Guangzhou, China; Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore
| | - Francois Venter
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng, South Africa
| | - Elvin H Geng
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO, USA
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Gill MM, Bakebua W, Ditekemena J, Gbomosa CN, Tshishi D, Loando A, Giri A, Ngantsui RB, Hoffman HJ. Virological and care outcomes of community ART distribution: Experience with the PODI+ model in Kinshasa, Democratic Republic of the Congo. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0002343. [PMID: 38295044 PMCID: PMC10830041 DOI: 10.1371/journal.pgph.0002343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 12/12/2023] [Indexed: 02/02/2024]
Abstract
INTRODUCTION Differentiated service delivery models for HIV treatment can minimize unnecessary burdens on health systems and promote efficient delivery of antiretroviral therapy (ART). Under the PODI+ (poste de distribution communautaire) model, ART multi-month dispensation (MMD) was provided by lay workers (peers) in communities. We compared outcomes among clinically stable adults living with HIV receiving MMD via PODI+ or health facility (HF). METHODS Clients receiving MMD at nine HFs and two PODI+ sites in Kinshasa were followed prospectively for one year (2018-2020). Medication possession ratio (MPR) was measured as proportion of total days with medication during the study through record abstraction at 3-month intervals. Viral load was assessed at enrollment and 12 months. We compared MPR and viral load suppression by arm and examined associations and potential confounders using unadjusted and adjusted odds ratios (AOR). Likert-style client satisfaction was collected during 12-month interviews and described by arm. RESULTS Odds of maintaining viral load suppression at 12 months for PODI+ participants were two times that for HF participants. In adjusted models, PODI+ participants had 1.89 times the odds of being suppressed at 12 months compared to HF participants (95% CI: 1.10, 3.27). No significant differences in MPR were found between groups (OR: 0.86, 0.38-1.99). Older participants had significantly higher odds of MPR (AOR: 1.02, 95% CI: 1.01, 1.03) and viral suppression (AOR: 1.03, 95% CI: 1.00, 1.07). Satisfaction with services was ≥87% overall, but PODI+ participants rated time spent at site, provider attributes and other care aspects more favorably. CONCLUSIONS Participants receiving MMD via peer-run community distribution points had similar MPR, but better virological outcomes and greater satisfaction with care than clinically similar participants receiving MMD through facilities. PODI+ could be a useful model for expansion to serve larger clinic populations from overburdened health facilities, particularly as policy shifts towards more inclusive MMD eligibility requirements.
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Affiliation(s)
- Michelle M. Gill
- Elizabeth Glaser Pediatric AIDS Foundation, Washington, District of Columbia, United States of America
| | - Winnie Bakebua
- Elizabeth Glaser Pediatric AIDS Foundation, Kinshasa, Democratic Republic of the Congo
| | - John Ditekemena
- Elizabeth Glaser Pediatric AIDS Foundation, Kinshasa, Democratic Republic of the Congo
| | | | - Dieudonné Tshishi
- Elizabeth Glaser Pediatric AIDS Foundation, Kinshasa, Democratic Republic of the Congo
| | - Aimé Loando
- Elizabeth Glaser Pediatric AIDS Foundation, Kinshasa, Democratic Republic of the Congo
| | - Abhigya Giri
- Department of Biostatistics and Bioinformatics, Milken Institute School of Public Health, The George Washington University, Washington, District of Columbia, United States of America
| | - Roger Beni Ngantsui
- DRC Ministry of Health, National AIDS Control Program, Kinshasa, Democratic Republic of the Congo
| | - Heather J. Hoffman
- Department of Biostatistics and Bioinformatics, Milken Institute School of Public Health, The George Washington University, Washington, District of Columbia, United States of America
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Bassett IV, Yan J, Giddy J, Ross D, Bogart LM, Stuckwisch A, Zionts D, Naidoo R, Parker RA. Geographic variation in 5-year mortality following HIV diagnosis: implications for clinical interventions. AIDS Care 2023; 35:2016-2023. [PMID: 36942651 PMCID: PMC10511661 DOI: 10.1080/09540121.2023.2189224] [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: 06/02/2022] [Accepted: 03/01/2023] [Indexed: 03/23/2023]
Abstract
Characterizing spatial distribution of HIV outcomes is vital for targeting interventions to areas most at risk. We performed spatial analysis to identify geographic clusters and factors associated with mortality in KwaZulu-Natal, South Africa. We utilized Sizanani trial (NCT01188941) data, which enrolled participants August 2010-January 2013 and obtained vital status at 5.8 (IQR 5.0-6.4) years of follow-up. We mapped geocoded addresses to 2011 Census-defined small area layer (SAL) centroids, used Kulldorff's spatial scan statistic to identify mortality clusters, and compared socio-demographic factors for SALs within and outside mortality clusters. We assigned 1,143 participants living with HIV (260 [23%] of whom died during follow-up) to 677 SALs. One lower mortality cluster (n = 90, RR = 0.23, p = 0.022) was identified near a hospital outside Durban. SALs in the cluster were younger (24y vs 25y, p < 0.001); had fewer bedrooms/household (3 vs 4, p < 0.001); had more females (52% vs 51%, p = 0.013) and residents with no schooling past age 20 (4% vs 3%, p < 0.001) or no education at all (4% vs 3%, p < 0.001); had fewer residents with income >3,200 ZAR/month (5% vs 9%, p < 0.001); and had reduced access to piped water (p < 0.001), refuse disposal (p < 0.001), and toilets (p < 0.001). Targeted interventions may improve outcomes in areas with similar characteristics.
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Affiliation(s)
- Ingrid V. Bassett
- Massachusetts General Hospital, Division of Infectious Diseases, Boston, Massachusetts, United States of America
- Massachusetts General Hospital, Medical Practice Evaluation Center, Boston, Massachusetts, United States of America
- Harvard University, Center for AIDS Research (CFAR), Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
| | - Joyce Yan
- Massachusetts General Hospital, Biostatistics Center, Boston, Massachusetts, United States of America
| | | | - Douglas Ross
- St. Mary’s Hospital, Mariannhill, Durban, South Africa*
| | - Laura M. Bogart
- RAND Corporation, Santa Monica, California, United States of America
| | - Ashley Stuckwisch
- Massachusetts General Hospital, Medical Practice Evaluation Center, Boston, Massachusetts, United States of America
| | - Dani Zionts
- Massachusetts General Hospital, Medical Practice Evaluation Center, Boston, Massachusetts, United States of America
| | - Ravi Naidoo
- Statistics South Africa, KwaZulu-Natal Provincial Office, Durban, South Africa
| | - Robert A. Parker
- Massachusetts General Hospital, Biostatistics Center, Boston, Massachusetts, United States of America
- Harvard University, Center for AIDS Research (CFAR), Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
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Ndlovu S, Ross A, Mulondo M. Interventions to improve young men's utilisation of HIV-testing services in KwaZulu-Natal, South Africa: perspectives of young men and health care providers. AFRICAN JOURNAL OF AIDS RESEARCH : AJAR 2023; 22:316-326. [PMID: 38117741 DOI: 10.2989/16085906.2023.2276897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 10/01/2023] [Indexed: 12/22/2023]
Abstract
Introduction: HIV-testing services (HTS) are an important point of entry to prevention and treatment of HIV in South Africa. Despite the availability of HTS across the region and in SA, the uptake among men remains low, especially young men residing in rural and peri-urban communities. This study aimed to explore interventions that could improve the uptake of HTS among young men in KwaZulu-Natal.Methods: A descriptive exploratory qualitative study was conducted in which 17 young men and two health care providers in Ladysmith were purposively and conveniently sampled. Data were collected through semi-structured interviews using WhatsApp and landline audio calls between September and December 2021 and thematically analysed.Results: An improvement in the health care provider attitudes and service delivery, establishment of adherence clubs for young people living with HIV, ensuring a diverse and balanced health care provider staff composition at primary health care facilities, and increased demand creation in spaces frequented by men are vital for enhancing access and utilisation of HTS among young men. Additionally, health care providers believe that the presence of male health care providers, investment in health education, prioritising men in the morning at the primary health care facilities, and the establishment of male clinics within communities as key factors in improving the uptake of HTS among young men.Conclusion: To attract and retain young men in HTS and in HIV treatment and care, several improvements at primary health care facilities need to be implemented. These should focus on addressing the specific needs and preferences of young men, ensuring their comfort and engagement in health care.
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Affiliation(s)
- Sithembiso Ndlovu
- Department of Family Medicine, Faculty of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
- Office of the Dean, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa
| | - Andrew Ross
- Department of Family Medicine, Faculty of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Mutshidzi Mulondo
- Office of the Dean, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa
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Bwire GM, Njiro BJ, Ndumwa HP, Munishi CG, Mpondo BC, Mganga M, Mang'ombe E, Bakari M, Sangeda RZ, Sudfeld CR, Killewo J. Impact of differentiated service delivery models on retention in HIV care and viral suppression among people living with HIV in sub-Saharan Africa: A systematic review and meta-analysis of randomised controlled trials. Rev Med Virol 2023; 33:e2479. [PMID: 37655428 PMCID: PMC10840667 DOI: 10.1002/rmv.2479] [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: 06/09/2023] [Revised: 08/03/2023] [Accepted: 08/25/2023] [Indexed: 09/02/2023]
Abstract
Differentiated service delivery (DSD) models, such as adherence clubs (ACs), are client-centred approaches where clinically stable people living with HIV (PLHIV) meet to receive various services, including psychosocial support, brief symptoms screening, and refills of antiretroviral medications, among others. We conducted a review to assess the impact of DSD models, including ACs, on sustaining retention in care (RC) and achieving viral suppression (VS) among PLHIV in sub-Saharan Africa. The review protocol was registered in PROSPERO (CRD42023418988). We searched the literature from PubMed, Scopus, Web of Science, Embase and Google Scholar from their inception through May 2023. Eligible randomised controlled trials of adherence clubs were reviewed to assess impact on retention and viral suppression. Random effect models were used to estimate the risk ratios (RR) and 95% confidence intervals (CI). The literature search yielded a total of 1596 records of which 16 randomised clinical trials were determined to be eligible. The trials were conducted in diverse populations among adults and children with a total of 13,886 participants. The RR between any DSD models and standard of care (SoC) was 1.09 (95% CI: 1.08-1.11, I2 : 0%, p: <0.96) and 1.01 (95% CI: 1.00-1.02, I2 : 0%, p: <0.85) for RC and VS, respectively. The RR between ACs and SoC was 1.01 (95% CI: 0.96-1.07, I2 : 84%, p: <0.01) and 1.02 (95% CI: 0.98-1.07, I2 : 77%, p: <0.01) for RC and VS, respectively. DSD models, including ACs, show comparable effectiveness to SoC in maintaining care and achieving viral suppression for stable PLHIV. To maximise adoption, an implementation science approach is crucial for designing effective strategies and overcoming challenges.
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Affiliation(s)
- George M Bwire
- Department of Pharmaceutical Microbiology, School of Pharmacy, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
- Department of Microbiology, Immunology and Transplantation, Rega Institute for Medical Research Clinical and Epidemiological Virology, Institute for the Future, KU Leuven, Leuven, Belgium
| | - Belinda J Njiro
- Department of Epidemiology and Biostatistics, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
- Division of Epidemiology and Biostatistics, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Harieth P Ndumwa
- Department of Community Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
- Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Castory G Munishi
- Department of Pharmaceutics and Pharmacy Practice, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | | | - Mathew Mganga
- President's Office-Regional Administration and Local Government, Dodoma, Tanzania
| | - Emmanuel Mang'ombe
- Department of Microbiology and Parasitology, School of Medicine and Dentistry, University of Dodoma, Dodoma, Tanzania
| | - Muhammad Bakari
- Department of Internal Medicine, School of Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Raphael Z Sangeda
- Department of Pharmaceutical Microbiology, School of Pharmacy, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Christopher R Sudfeld
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Japthet Killewo
- Department of Epidemiology and Biostatistics, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
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11
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Pinto PFPS, Macinko J, Silva AF, Lua I, Jesus G, Magno L, Santos CAST, Ichihara MY, Barreto ML, Moucheraud C, Souza LE, Dourado I, Rasella D. The effect of primary health care on AIDS incidence and mortality: a cohort study of 3.4 million Brazilians. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.10.02.23296417. [PMID: 37873240 PMCID: PMC10593023 DOI: 10.1101/2023.10.02.23296417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
Background Primary Health Care (PHC) is essential for the health and wellbeing of people living with HIV/AIDS. This study evaluated the effects of one of the largest community-based PHC programs in the world, the Brazilian Family Health Strategy (FHS), on AIDS incidence and mortality. Methods A retrospective cohort study carried out in Brazil, from January 1 2007 to December 31 2015. We conducted a quasi-experimental effect evaluation using a cohort of 3,435,068 ≥13 years low-income individuals who were members of the 100 Million Brazilians Cohort, linked to AIDS diagnoses and deaths registries. We evaluated the effect of FHS on AIDS incidence and mortality and comparing outcomes between residents of municipalities with no FHS coverage with those in municipalities with full FHS coverage. We used multivariable Poisson regressions adjusted for all relevant municipal and individual-level demographic, socioeconomic, and contextual variables, and weighted with inverse probability of treatment weighting (IPTW). We also estimated FHS effect by sex and age, and performed a wide range of sensitivity and triangulation analyses. Findings FHS coverage was associated with lower AIDS incidence (rate ratio [RR]:0.76, 95%CI:0.68-0.84) and mortality (RR:0.68,95%CI:0.56-0.82). FHS effect was similar between men and women, but was larger in people aged ≥35 years old both for incidence (RR 0.62, 95%CI:0.53-0.72) and mortality (RR 0.56, 95%CI:0.43-0.72). Conclusions AIDS should be an avoidable outcome for most people living with HIV today, and our study shows that FHS coverage could significantly reduce AIDS incidence and mortality among low-income populations in Brazil. Universal access to comprehensive healthcare through community-based PHC programs should be promoted to achieve the Sustainable Development Goals of ending AIDS by 2030.
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Affiliation(s)
- Priscila FPS Pinto
- Institute of Collective Health, Federal University of Bahia (ISC/UFBA), Salvador, Brazil
- The Centre for Data and Knowledge Integration for Health (CIDACS-Fiocruz), Salvador, Brazil
| | - James Macinko
- Departments of Health Policy and Management and Community Health Sciences, Fielding School of Public Health, University of California (UCLA), Los Angeles, California, The United States of America (USA)
| | - Andréa F Silva
- Institute of Collective Health, Federal University of Bahia (ISC/UFBA), Salvador, Brazil
- The Centre for Data and Knowledge Integration for Health (CIDACS-Fiocruz), Salvador, Brazil
| | - Iracema Lua
- Institute of Collective Health, Federal University of Bahia (ISC/UFBA), Salvador, Brazil
- The Centre for Data and Knowledge Integration for Health (CIDACS-Fiocruz), Salvador, Brazil
| | - Gabriela Jesus
- Institute of Collective Health, Federal University of Bahia (ISC/UFBA), Salvador, Brazil
- The Centre for Data and Knowledge Integration for Health (CIDACS-Fiocruz), Salvador, Brazil
| | - Laio Magno
- Department of Life Sciences, State University of Bahia (UNEB), Salvador, Brazil
| | - Carlos AS Teles Santos
- The Centre for Data and Knowledge Integration for Health (CIDACS-Fiocruz), Salvador, Brazil
| | - Maria Yury Ichihara
- The Centre for Data and Knowledge Integration for Health (CIDACS-Fiocruz), Salvador, Brazil
| | - Mauricio L Barreto
- The Centre for Data and Knowledge Integration for Health (CIDACS-Fiocruz), Salvador, Brazil
| | - Corrina Moucheraud
- Departments of Health Policy and Management and Community Health Sciences, Fielding School of Public Health, University of California (UCLA), Los Angeles, California, The United States of America (USA)
| | - Luis E Souza
- Institute of Collective Health, Federal University of Bahia (ISC/UFBA), Salvador, Brazil
| | - Inês Dourado
- Institute of Collective Health, Federal University of Bahia (ISC/UFBA), Salvador, Brazil
| | - Davide Rasella
- Institute of Collective Health, Federal University of Bahia (ISC/UFBA), Salvador, Brazil
- Instituto de Salud Global Barcelona (ISGlobal), Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
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12
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Nicol E, Jama NA, Mehlomakulu V, Hlongwa M, Pass D, Basera W, Bradshaw D. Enhancing linkage to HIV care in the "Universal Test and Treat" era: Barriers and enablers to HIV care among adults in a high HIV burdened district in KwaZulu-Natal, South Africa. BMC Public Health 2023; 23:1756. [PMID: 37689667 PMCID: PMC10492313 DOI: 10.1186/s12889-023-16576-w] [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: 04/04/2023] [Accepted: 08/21/2023] [Indexed: 09/11/2023] Open
Abstract
Ending AIDS by 2030 would depend on how successful health systems are in linking people living with HIV (PLHIV) into care. The World Health Organization recommended the 'Universal Test and Treat' (UTT) strategy - initiating all individuals testing positive on antiretroviral therapy (ART) irrespective of their CD4 count and clinical staging. This study aimed to explore the enablers and barriers to linkage to HIV care among adults with a new HIV diagnosis in a high-HIV prevalent rural district in South Africa. A qualitative study was undertaken to explore patients' perceptions of enablers and barriers of linkage-to-care, using a life-story narration and dialogue approach. In-depth interviews were conducted with 38 HIV-positive participants sampled from a cohort of 1194 HIV-positive patients recruited from December 2017 to June 2018. Participants were selected based on whether they had been linked to care or not within 3 months of positive HIV diagnosis. Interviews were thematically analysed using a general inductive approach. Of the 38 participants, 22 (58%) linked to care within three months of HIV-positive diagnosis. Factors that facilitated or inhibited linkage-to-care were found at individual, family, community, as well as health systems levels. Enablers included a positive HIV testing experience, and assistance from the fieldwork team. Support from family, and friends, as well as prior community-based education about HIV and ART were also noted. Individual factors such as acceptance of HIV status, previous exposure to PLHIV, and fear of HIV progressing, were identified. Barriers to linkage included, denial of HIV status, dislike of taking pills, and preference for alternative medicine. Negative experiences with counselling and health systems inefficiency were also noted as barriers. Perceived stigma and socio-economic factors, such as lack of food or money to visit the clinic were other barriers. Community-based and health system-level interventions would need to focus on clinic readiness in providing patients with necessary and effective health services such as proper and adequate counselling. This could increase the number of patients who link to care. Finally, interventions to improve linkage-to-care should consider a holistic approach, including training healthcare providers, community outreach and the provision of psychological, social, and financial support.
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Affiliation(s)
- Edward Nicol
- Burden of Disease Research Unit, South African Medical Research Council, P.O. Box 19070, TygerbergCape Town, 7505, South Africa.
- Division of Health Systems and Public Health, Stellenbosch University, Cape Town, South Africa.
| | - Ngcwalisa Amanda Jama
- Burden of Disease Research Unit, South African Medical Research Council, P.O. Box 19070, TygerbergCape Town, 7505, South Africa
- School of Public Health, University of the Western Cape, Bellville, South Africa
| | - Vuyelwa Mehlomakulu
- Burden of Disease Research Unit, South African Medical Research Council, P.O. Box 19070, TygerbergCape Town, 7505, South Africa
| | - Mbuzeleni Hlongwa
- Burden of Disease Research Unit, South African Medical Research Council, P.O. Box 19070, TygerbergCape Town, 7505, South Africa
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
- Public Health, Societies and Belonging, Human Sciences Research Council, Pretoria, South Africa
| | - Desiree Pass
- Burden of Disease Research Unit, South African Medical Research Council, P.O. Box 19070, TygerbergCape Town, 7505, South Africa
| | - Wisdom Basera
- Burden of Disease Research Unit, South African Medical Research Council, P.O. Box 19070, TygerbergCape Town, 7505, South Africa
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Debbie Bradshaw
- Burden of Disease Research Unit, South African Medical Research Council, P.O. Box 19070, TygerbergCape Town, 7505, South Africa
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
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13
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Pascoe S, Huber A, Mokhele I, Lekodeba N, Ntjikelane V, Sande L, Tchereni T, Haimbe P, Rosen S. The SENTINEL study of differentiated service delivery models for HIV treatment in Malawi, South Africa, and Zambia: research protocol for a prospective cohort study. BMC Health Serv Res 2023; 23:891. [PMID: 37612720 PMCID: PMC10463463 DOI: 10.1186/s12913-023-09813-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 07/13/2023] [Indexed: 08/25/2023] Open
Abstract
BACKGROUND Many countries in sub-Saharan Africa are rapidly scaling up "differentiated service delivery" (DSD) models for HIV treatment to improve the quality of care, increase access, reduce costs, and support the continued expansion and sustainability of antiretroviral therapy (ART) programs. Although there is some published evidence about the health outcomes of patients in DSD models, little is known about their impacts on healthcare providers' job satisfaction, patients' quality of life, costs to providers or patients, or how DSD models affect resource allocation at the facility level. METHODS SENTINEL is a multi-year observational study that will collect detailed data about DSD models for ART delivery and related services from 12 healthcare facilities in Malawi, 24 in South Africa, and 12 in Zambia. The first round of SENTINEL included a patient survey, provider survey, provider time-and-motion observations, and facility resource use inventory. A survey of clients testing for HIV and a supplement to the facility resource use component to describe service delivery integration will be added for the second round. The patient survey will ask up to 10 patients enrolled in each DSD model at each study site about their experiences in HIV care and in DSD models, costs incurred seeking treatment, and preferences for HIV service delivery. The provider survey will ask up to 10 providers per site about the impact of DSD models on their positions and clinics. The time-and-motion component will directly observe the time use of a sample of providers implementing DSD models. Finally, the resource utilization component will collect facility-level data about DSD model availability and enrollment and the human and other resources needed to implement them. SENTINEL is planned to include four or more approximately annual rounds of data collection between 2021 and 2026. DISCUSSION As national DSD programs for HIV treatment mature, it is important to understand how individual healthcare facilities are interpreting and implementing national guidelines and how healthcare workers and clients are adapting to new models of service delivery. SENTINEL will help policy makers and program managers understand the benefits and costs of differentiated service delivery and improve resource allocation going forward.
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Affiliation(s)
- Sophie Pascoe
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Sunnyside Office Park, Building C, First Floor, 32 Princess of Wales Terrace, Parktown, Johannesburg, 2193, South Africa
| | - Amy Huber
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Sunnyside Office Park, Building C, First Floor, 32 Princess of Wales Terrace, Parktown, Johannesburg, 2193, South Africa
| | - Idah Mokhele
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Sunnyside Office Park, Building C, First Floor, 32 Princess of Wales Terrace, Parktown, Johannesburg, 2193, South Africa
| | - Nkgomeleng Lekodeba
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Sunnyside Office Park, Building C, First Floor, 32 Princess of Wales Terrace, Parktown, Johannesburg, 2193, South Africa
| | - Vinolia Ntjikelane
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Sunnyside Office Park, Building C, First Floor, 32 Princess of Wales Terrace, Parktown, Johannesburg, 2193, South Africa
| | - Linda Sande
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Sunnyside Office Park, Building C, First Floor, 32 Princess of Wales Terrace, Parktown, Johannesburg, 2193, South Africa
| | - Timothy Tchereni
- Clinton Health Access Initiative-Malawi, Private Bag 68, Lilongwe, Malawi
| | - Prudence Haimbe
- Clinton Health Access Initiative-Zambia, P.O. Box 51071, Ridgeway, Lusaka, Zambia
| | - Sydney Rosen
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, University of the Witwatersrand, Sunnyside Office Park, Building C, First Floor, 32 Princess of Wales Terrace, Parktown, Johannesburg, 2193, South Africa.
- Department of Global Health, School of Public Health, Boston University, 801 Massachusetts Ave, 3rd Fl, Boston, MA, 02118, USA.
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Randera-Rees S, Clarence Safari W, Gareta D, Herbst K, Baisley K, Grant AD. Can we find the missing men in clinics? Clinic attendance by sex and HIV status in rural South Africa. Wellcome Open Res 2023; 6:169. [PMID: 37767058 PMCID: PMC10521066 DOI: 10.12688/wellcomeopenres.16702.2] [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: 07/12/2023] [Indexed: 09/29/2023] Open
Abstract
Background: HIV-negative men are over-represented in tuberculosis (TB) prevalence surveys including the first South African national TB prevalence survey in 2018. Traditionally, TB screening is focused in clinics. We aimed to determine the frequency of primary healthcare clinic (PHC) attendance among HIV-negative men in a TB-prevalent setting. Methods: Since January 2017, PHC attendees in a rural South African demographic surveillance area (DSA) were asked their reason for attendance. HIV status was defined as positive if tested positive in a DSA sero-survey or attended clinic for HIV care; negative if tested negative between January 2014-December 2017 and no HIV-related visits; and HIV-unknown otherwise. Results: Among 67124 DSA residents (≥15 years), 27038 (40.3%) were men; 14196 (21.2%) were classified HIV-positive, 18892 (28.1%) HIV-negative and 34036 (50.7%) HIV-unknown. Between April 2017 and March 2018, 24382/67124 (36.3%, 95% confidence interval [CI] 36.0-36.7) adults made ≥1 PHC visit, comprising 9805/40086 (24.5%, 95%CI 23.6-25.3) of HIV-negative or unknown women and 3440/27038 (12.7%, 95%CI 11.6-13.8) of HIV-negative or unknown men. Overall, HIV care accounted for 37556/88109 (42.6%) of adult PHC visits. Conclusion: In this rural population, HIV-negative and -unknown men rarely attend PHCs. Improving TB screening in clinics may not reach a key population with respect to undiagnosed TB. Additional strategies are needed to diagnose and treat TB earlier.
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Affiliation(s)
- Safiyya Randera-Rees
- Africa Health Research Institute, KwaZulu Natal, South Africa
- National Health Laboratory Services, Johannesburg, 2192, South Africa
| | - Wende Clarence Safari
- Africa Health Research Institute, KwaZulu Natal, South Africa
- London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Dickman Gareta
- Africa Health Research Institute, KwaZulu Natal, South Africa
- DSI-MRC, South African Population Research Infrastructure Network, KwaZulu Natal, South Africa
| | - Kobus Herbst
- Africa Health Research Institute, KwaZulu Natal, South Africa
- DSI-MRC, South African Population Research Infrastructure Network, KwaZulu Natal, South Africa
| | - Kathy Baisley
- Africa Health Research Institute, KwaZulu Natal, South Africa
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - Alison D. Grant
- Africa Health Research Institute, KwaZulu Natal, South Africa
- London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
- School of Laboratory Medicine & Medical Sciences, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
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15
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Nicol E, Basera W, Mukumbang FC, Cheyip M, Mthethwa S, Lombard C, Jama N, Pass D, Laubscher R, Bradshaw D. Linkage to HIV Care and Early Retention in Care Rates in the Universal Test-and-Treat Era: A Population-based Prospective Study in KwaZulu-Natal, South Africa. AIDS Behav 2023; 27:1068-1081. [PMID: 36098845 PMCID: PMC10020822 DOI: 10.1007/s10461-022-03844-w] [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] [Accepted: 08/27/2022] [Indexed: 11/01/2022]
Abstract
HIV linkage, and retention are key weaknesses in South Africa's national antiretroviral therapy (ART) program, with the greatest loss of patients in the HIV treatment pathway occurring before ART initiation. This study investigated linkage-to and early-retention-in-care (LTRIC) rates among adults newly diagnosed with HIV in a high-HIV prevalent rural district. We conducted an observational prospective cohort study to investigate LTRIC rates for adults with a new HIV diagnosis in South Africa. Patient-level survey and clinical data were collected using a one-stage-cluster design from 18 healthcare facilities and triangulated between HIV and laboratory databases and registered deaths from Department of Home Affairs. We used Chi-square tests to assess associations between categorical variables, and results were stratified by HIV status, sex, and age. Of the 5,637 participants recruited, 21.2% had confirmed HIV, of which 70.9% were women, and 46.5% were aged 25-34 years. Although 82.7% of participants were linked-to-care within 3 months, only 46.1% remained-in-care 12 months after initiating ART and 5.2% were deceased. While a significantly higher proportion of men were linked-to-care at 3 months compared to women, a significant proportion of women (49.5%) remained-in-care at 12 months than men (38.0%). Post-secondary education and child support grants were significantly associated with retention. We found high linkage-to-care rates, but less than 50% of participants remained-in-care at 12 months. Significant effort is required to retain people living with HIV in care, especially during the first year after ART initiation. Our findings suggest that interventions could target men to encourage HIV testing.
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Affiliation(s)
- Edward Nicol
- Burden of Disease Research Unit, South African Medical Research Council, Tygerberg, 7505, Cape Town, P.O. Box 19070, South Africa.
- Division of Health Systems and Public Health, Stellenbosch University, Cape Town, South Africa.
| | - Wisdom Basera
- Burden of Disease Research Unit, South African Medical Research Council, Tygerberg, 7505, Cape Town, P.O. Box 19070, South Africa
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Ferdinand C Mukumbang
- Burden of Disease Research Unit, South African Medical Research Council, Tygerberg, 7505, Cape Town, P.O. Box 19070, South Africa
- School of Public Health, University of the Western Cape, Bellville, South Africa
| | - Mireille Cheyip
- Centers for Disease Control and Prevention, Pretoria, South Africa
| | | | - Carl Lombard
- Biostatistics, South African Medical Research Council, Cape Town, South Africa
| | - Ngcwalisa Jama
- Burden of Disease Research Unit, South African Medical Research Council, Tygerberg, 7505, Cape Town, P.O. Box 19070, South Africa
- School of Public Health, University of the Western Cape, Bellville, South Africa
| | - Desiree Pass
- Burden of Disease Research Unit, South African Medical Research Council, Tygerberg, 7505, Cape Town, P.O. Box 19070, South Africa
| | - Ria Laubscher
- Biostatistics, South African Medical Research Council, Cape Town, South Africa
| | - Debbie Bradshaw
- Burden of Disease Research Unit, South African Medical Research Council, Tygerberg, 7505, Cape Town, P.O. Box 19070, South Africa
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
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16
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Nicol E, Mehlomakulu V, Jama NA, Hlongwa M, Basera W, Pass D, Bradshaw D. Healthcare provider perceptions on the implementation of the universal test-and-treat policy in South Africa: a qualitative inquiry. BMC Health Serv Res 2023; 23:293. [PMID: 36978086 PMCID: PMC10045036 DOI: 10.1186/s12913-023-09281-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Accepted: 03/13/2023] [Indexed: 03/30/2023] Open
Abstract
BACKGROUND South Africa had an estimated 7.5 million people living with HIV (PLHIV), accounting for approximately 20% of the 38.4 million PLHIV globally in 2021. In 2015, the World Health Organization recommended the universal test and treat (UTT) intervention which was implemented in South Africa in September 2016. Evidence shows that UTT implementation faces challenges in terms of human resources capacity or infrastructure. We aim to explore healthcare providers (HCPs)' perspectives on the implementation of the UTT strategy in uThukela District Municipality in KwaZulu-Natal province. METHODS A qualitative study was conducted with one hundred and sixty-one (161) healthcare providers (HCPs) within 18 healthcare facilities in three subdistricts, comprising of Managers, Nurses, and Lay workers. HCPs were interviewed using an open ended-survey questions to explore their perceptions providing HIV care under the UTT strategy. All interviews were thematically analysed using both inductive and deductive approaches. RESULTS Of the 161 participants (142 female and 19 male), 158 (98%) worked at the facility level, of which 82 (51%) were nurses, and 20 (12.5%) were managers (facility managers and PHC manager/supervisors). Despite a general acceptance of the UTT policy implementation, HCPs expressed challenges such as increased patient defaulter rates, increased work overload, caused by the increased number of service users, and physiological and psychological impacts. The surge in the workload under conditions of inadequate systems' capacity and human resources, gave rise to a greater burden on HCPs in this study. However, increased life expectancy, good quality of life, and immediate treatment initiation were identified as perceived positive outcomes of UTT on service users. Perceived influence of UTT on the health system included, increased number of patients initiated, decreased burden on the system, meeting the 90-90-90 targets, and financial aspects. CONCLUSION Health system strengthening such as providing more systems' capacity for expected increase in workload, proper training and retraining of HCPs with new policies in the management of patient readiness for lifelong ART journey, and ensuring availability of medicines, may reduce strain on HCPs, thus improving the delivery of the comprehensive UTT services to PLHIV.
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Affiliation(s)
- Edward Nicol
- Burden of Disease Research Unit, South African Medical Research Council, P.O. Box 19070, Tygerberg, 7505, South Africa.
- Division of Health Systems and Public Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa.
| | - Vuyelwa Mehlomakulu
- Burden of Disease Research Unit, South African Medical Research Council, P.O. Box 19070, Tygerberg, 7505, South Africa
| | - Ngcwalisa Amanda Jama
- Burden of Disease Research Unit, South African Medical Research Council, P.O. Box 19070, Tygerberg, 7505, South Africa
- School of Public Health, University of the Western Cape, Cape Town, South Africa
| | - Mbuzeleni Hlongwa
- Burden of Disease Research Unit, South African Medical Research Council, P.O. Box 19070, Tygerberg, 7505, South Africa
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Wisdom Basera
- Burden of Disease Research Unit, South African Medical Research Council, P.O. Box 19070, Tygerberg, 7505, South Africa
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Desiree Pass
- Burden of Disease Research Unit, South African Medical Research Council, P.O. Box 19070, Tygerberg, 7505, South Africa
| | - Debbie Bradshaw
- Burden of Disease Research Unit, South African Medical Research Council, P.O. Box 19070, Tygerberg, 7505, South Africa
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
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Ramraj T, Chirinda W, Jonas K, Govindasamy D, Jama N, McClinton Appollis T, Zani B, Mukumbang FC, Basera W, Hlongwa M, Turawa EB, Mathews C, Nicol E. Service delivery models that promote linkages to PrEP for adolescent girls and young women and men in sub-Saharan Africa: a scoping review. BMJ Open 2023; 13:e061503. [PMID: 36972966 PMCID: PMC10069497 DOI: 10.1136/bmjopen-2022-061503] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/29/2023] Open
Abstract
BACKGROUND Pre-exposure prophylaxis (PrEP) is an emerging biomedical prevention intervention. Documenting PrEP service delivery models (SDMs) that promote linkage to and continuation of PrEP will inform guidelines and maximise roll-out. OBJECTIVES To synthesise and appraise the effectiveness and feasibility of PrEP SDMs designed to promote linkage to PrEP care among adolescent girls and young women (AGYW) and men in sub-Saharan Africa (SSA). ELIGIBILITY CRITERIA Primary quantitative and qualitative studies published in English and conducted in SSA were included. No restrictions on the date of publication were applied. SOURCES OF EVIDENCE Methodology outlined in the Joanna Briggs Institute reviewers' manual was followed. PubMed, Cochrane library, Scopus, Web of Science and online-conference abstract archives were searched. CHARTING METHODS Data on article, population, intervention characteristics and key outcomes was charted in REDCap. RESULTS AND CONCLUSION Of the 1204 identified records, 37 (met the inclusion criteria. Health facility-based integrated models of PrEP delivery with family planning, maternal and child health or sexual and reproductive services to AGYW resulted in PrEP initiation of 16%-90%. Community-based drop-in centres (66%) was the preferred PrEP outlet for AGYW compared with public clinics (25%) and private clinics (9%). Most men preferred community-based delivery models. Among individuals who initiated PrEP, 50% were men, 62% were <35 years old and 97% were tested at health fairs compared with home testing. Integrated antiretroviral therapy (ART)-PrEP delivery was favoured among serodiscordant couples with 82.9% of couples using PrEP or ART with no HIV seroconversions. PrEP initiation within healthcare facilities was increased by perceived client-friendly services and non-judgemental healthcare workers. Barriers to PrEP initiation included distance to travel to and time spent at health facilities and perceived community stigma. PrEP SDMs for AGYW and men need to be tailored to the needs and preferences for each group. Programme implementers should promote community-based SDMs to increase PrEP initiation among AGYW and men.
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Affiliation(s)
- Trisha Ramraj
- HIV and Other Infectious Diseases Research Unit, South African Medical Research Council, Durban, KwaZulu-Natal, South Africa
| | - Witness Chirinda
- Health Systems Research Unit, South African Medical Research Council, Tygerberg, Western Cape, South Africa
| | - Kim Jonas
- Health Systems Research Unit, South African Medical Research Council, Tygerberg, Western Cape, South Africa
- Adolescent Health Research Unit, University of Cape Town, Rondebosch, Western Cape, South Africa
| | - Darshini Govindasamy
- Health Systems Research Unit, South African Medical Research Council, Tygerberg, Western Cape, South Africa
- Adolescent Health Research Unit, University of Cape Town, Rondebosch, Western Cape, South Africa
| | - Ngcwalisa Jama
- Burden of Disease Research Unit, South African Medical Research Council, Tygerberg, Western Cape, South Africa
| | - Tracy McClinton Appollis
- Health Systems Research Unit, South African Medical Research Council, Tygerberg, Western Cape, South Africa
- Adolescent Health Research Unit, University of Cape Town, Rondebosch, Western Cape, South Africa
| | - Babalwa Zani
- Burden of Disease Research Unit, South African Medical Research Council, Tygerberg, Western Cape, South Africa
| | - Ferdinand C Mukumbang
- Burden of Disease Research Unit, South African Medical Research Council, Tygerberg, Western Cape, South Africa
| | - Wisdom Basera
- Burden of Disease Research Unit, South African Medical Research Council, Tygerberg, Western Cape, South Africa
| | - Mbuzeleni Hlongwa
- Burden of Disease Research Unit, South African Medical Research Council, Tygerberg, Western Cape, South Africa
- College of Health Sciences, School of Nursing and Public Health Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Eunice B Turawa
- Burden of Disease Research Unit, South African Medical Research Council, Tygerberg, Western Cape, South Africa
- Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, Western Cape, South Africa
| | - Catherine Mathews
- Health Systems Research Unit, South African Medical Research Council, Tygerberg, Western Cape, South Africa
- Adolescent Health Research Unit, University of Cape Town, Rondebosch, Western Cape, South Africa
| | - Edward Nicol
- Burden of Disease Research Unit, South African Medical Research Council, Tygerberg, Western Cape, South Africa
- Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, Western Cape, South Africa
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Abstract
In this Policy Forum, Anna Grimsrud and colleagues discuss the future of HIV testing in eastern and southern Africa, using insights gleaned from a 2021 expert consultation.
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van Heerden A, Szpiro A, Ntinga X, Celum C, van Rooyen H, Essack Z, Barnabas R. A Sequential Multiple Assignment Randomized Trial of scalable interventions for ART delivery in South Africa: the SMART ART study. Trials 2023; 24:32. [PMID: 36647092 PMCID: PMC9842495 DOI: 10.1186/s13063-022-07025-x] [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: 11/08/2022] [Accepted: 12/15/2022] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Of the 8 million people in South Africa living with HIV, 74% of persons living with HIV are on antiretroviral therapy (ART) and 65% are virally suppressed. Detectable viral load results in HIV-associated morbidity and mortality and HIV transmission. Patient barriers to care, such as missed wages, transport costs, and long wait times for clinic visits and ART refills, are associated with detectable viral load. HIV differentiated service delivery (DSD) has simplified ART delivery for clients who achieve viral suppression and engage in care. However, DSD needs adaptation to serve clients who are not engaged in care. METHODS A Sequential Multiple Assignment Randomized Trial will be undertaken in KwaZulu-Natal, South Africa, to test adaptive ART delivery for persons with detectable viral load and/or who are not engaged in care. The types of differentiated service delivery (DSD) which will be examined in this study are clinic-based incentives, community-based smart lockers, and home delivery. The study plans to enroll up to 900 participants-people living with HIV, eligible for ART, and who are not engaged in care. The study aims to assess the proportion of ART-eligible persons living with HIV who achieve viral suppression at 18 months. The study will also evaluate the preferences of clients and providers for differentiated service delivery and evaluate the cost-effectiveness of adaptive HIV treatment for those who are not engaged in care. DISCUSSION To increase population-level viral suppression, persons with detectable viral load need responsive DSD interventions. A Sequential Multiple Assignment Randomized Trial (SMART) design facilitates the evaluation of a stepped, adaptive approach to achieving viral suppression with "right-sized" interventions for patients most in need of effective and efficient HIV care delivery strategies. TRIAL REGISTRATION ClinicalTrials.gov NCT05090150. Registered on October 22, 2021.
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Affiliation(s)
- Alastair van Heerden
- grid.417715.10000 0001 0071 1142Centre for Community Based Research, Human Sciences Research Council, Pietermaritzburg, South Africa ,grid.11951.3d0000 0004 1937 1135MRC/Wits Developmental Pathways for Health Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Adam Szpiro
- grid.34477.330000000122986657Department of Global Health, University of Washington, Seattle, WA USA ,grid.34477.330000000122986657Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA USA
| | - Xolani Ntinga
- grid.417715.10000 0001 0071 1142Centre for Community Based Research, Human Sciences Research Council, Pietermaritzburg, South Africa
| | - Connie Celum
- grid.34477.330000000122986657Department of Global Health, University of Washington, Seattle, WA USA ,grid.34477.330000000122986657Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA USA
| | - Heidi van Rooyen
- grid.11951.3d0000 0004 1937 1135MRC/Wits Developmental Pathways for Health Research Unit, University of the Witwatersrand, Johannesburg, South Africa ,grid.417715.10000 0001 0071 1142Human Sciences Research Council, Pietermaritzburg, South Africa
| | - Zaynab Essack
- grid.417715.10000 0001 0071 1142Centre for Community Based Research, Human Sciences Research Council, Pietermaritzburg, South Africa
| | - Ruanne Barnabas
- grid.32224.350000 0004 0386 9924Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA USA ,grid.38142.3c000000041936754XHarvard Medical School, Boston, MA USA
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Jo Y, Jamieson L, Phiri B, Grimsrud A, Mwansa M, Shakwelele H, Haimbe P, Mukumbwa-Mwenechanya M, Mulenga PL, Nichols BE, Rosen S. Attrition from HIV treatment after enrollment in a differentiated service delivery model: A cohort analysis of routine care in Zambia. PLoS One 2023; 18:e0280748. [PMID: 36917568 PMCID: PMC10013882 DOI: 10.1371/journal.pone.0280748] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 01/07/2023] [Indexed: 03/16/2023] Open
Abstract
BACKGROUND Many sub-Saharan Africa countries are scaling up differentiated service delivery (DSD) models for HIV treatment to increase access and remove barriers to care. We assessed factors associated with attrition after DSD model enrollment in Zambia, focusing on patient-level characteristics. METHODS We conducted a retrospective record review using electronic medical records (EMR) of adults (≥15 years) initiated on antiretroviral (ART) between 01 January 2018 and 30 November 2021. Attrition was defined as lost to follow-up (LTFU) or died by November 30, 2021. We categorized DSD models into eight groups: fast-track, adherence groups, community pick-up points, home ART delivery, extended facility hours, facility multi-month dispensing (MMD, 4-6-month ART dispensing), frequent refill care (facility 1-2 month dispensing), and conventional care (facility 3 month dispensing, reference group). We used Fine and Gray competing risk regression to assess patient-level factors associated with attrition, stratified by sex and rural/urban setting. RESULTS Of 547,281 eligible patients, 68% (n = 372,409) enrolled in DSD models, most commonly facility MMD (n = 306,430, 82%), frequent refill care (n = 47,142, 13%), and fast track (n = 14,433, 4%), with <2% enrolled in the other DSD groups. Retention was higher in nearly all DSD models for all dispensing intervals, compared to the reference group, except fast track for the ≤2 month dispensing group. Retention benefits were greatest for patients in the extended clinic hours group and least for fast track dispensing. CONCLUSION Although retention in HIV treatment differed by DSD type, dispensing interval, and patient characteristics, nearly all DSD models out-performed conventional care. Understanding the factors that influence the retention of patients in DSD models could provide an important step towards improving DSD implementation.
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Affiliation(s)
- Youngji Jo
- Department of Medicine, Section of Infectious Diseases, Boston Medical Center, Boston, MA, United States of America
| | - Lise Jamieson
- Department of Internal Medicine, Health Economics and Epidemiology Research Office, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Medical Microbiology, Amsterdam University Medical Center, Amsterdam, Netherlands
| | - Bevis Phiri
- Clinton Health Access Initiative, Lusaka, Zambia
| | - Anna Grimsrud
- HIV Programmes and Advocacy, International AIDS Society, Cape Town, South Africa
| | | | | | | | | | | | - Brooke E. Nichols
- Department of Internal Medicine, Health Economics and Epidemiology Research Office, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Medical Microbiology, Amsterdam University Medical Center, Amsterdam, Netherlands
- Department of Global Health, Boston University School of Public Health, Boston, MA, United States of America
| | - Sydney Rosen
- Department of Internal Medicine, Health Economics and Epidemiology Research Office, 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, United States of America
- * E-mail:
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21
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Babatunde AO, Akin-Ajani OD, Abdullateef RO, Togunwa TO, Isah HO. Review of antiretroviral therapy coverage in 10 highest burden HIV countries in Africa: 2015-2020. J Med Virol 2023; 95:e28320. [PMID: 36397202 DOI: 10.1002/jmv.28320] [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: 07/24/2022] [Revised: 10/19/2022] [Accepted: 11/15/2022] [Indexed: 11/19/2022]
Abstract
Africa is responsible for two-thirds of the global total of new HIV infections. South Africa, Nigeria, Mozambique, Uganda, Tanzania, Zambia, Zimbabwe, Kenya, Malawi, and Ethiopia were responsible for 80% of HIV cases in Africa in 2014 according to the Joint United Nations Programme on HIV/AIDS (UNAIDS). This study assesses antiretroviral coverage strategies implemented by these countries after the initiation of the "Fast-Track strategy to end the AIDS epidemic by 2030." Data reported in this review were obtained from different e-bibliographic including PubMed, Google Scholar, and Research Gate. Key terms were "Antiretroviral therapy," "Antiretroviral treatment," "HIV treatment," "HIV medication," "HIV/AIDS therapy," "HIV/AIDS treatment" + each of the countries listed earlier. We also extracted data on antiretroviral therapy (ART) coverage from the UNAIDS database. About 50 papers published from 2015 to 2021 met the inclusion criteria. All 10 countries have experienced an increase in ART coverage from 2015 to 2020 with an average of 47.6% increment. Nigeria recorded the highest increase in the rate of ART coverage (72% increase) while Ethiopia had the least (30%). New strategies adopted to increase ART coverage and retention in most countries were community-based models and the use of mobile health technology rather than clinic-based. These strategies focus on promoting task shifting, door-to-door access to HIV services, and a long-term supply of antiretroviral medications. Most of these strategies are still in the piloting stage. However, some new strategies and frameworks have been adopted nationwide in countries like Mozambique, Tanzania, Zambia, Zimbabwe, Kenya, and Malawi. Identified challenges include lack of funding, inadequate testing and surveillance services, poor digital penetration, and cultural/religious beliefs. The adoption of community-based and digital health strategies could have contributed to increased ART coverage and retention. African countries should facilitate nationwide scaling of ART coverage strategies to attain the 95-95-95 goal by 2030.
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Affiliation(s)
- Abdulhammed O Babatunde
- Department of Medicine and Surgery, Faculty of Clinical Sciences, College of Medicine, University of Ibadan, Ibadan, Nigeria.,Healthy Africans Platform, Ibadan, Nigeria.,Federation of African Medical Students' Associations, Ibadan, Nigeria
| | - Oluwawapelumi D Akin-Ajani
- Department of Medicine and Surgery, Faculty of Clinical Sciences, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Ridwanullah O Abdullateef
- Department of Medicine and Surgery, Faculty of Clinical Sciences, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Taofeeq O Togunwa
- Department of Medicine and Surgery, Faculty of Clinical Sciences, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Haroun O Isah
- Department of Community Medicine and Primary Health Care, College of Medicine and Health Sciences, Bingham University, Jos, Nigeria
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22
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Roomaney RA, van Wyk B, Pillay-van Wyk V. Multimorbidity in South Africa: Is the health system ready? JOURNAL OF MULTIMORBIDITY AND COMORBIDITY 2023; 13:26335565231182483. [PMID: 37342320 PMCID: PMC10278409 DOI: 10.1177/26335565231182483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 05/30/2023] [Indexed: 06/22/2023]
Abstract
Background: Multimorbidity is likely to be a significant contributor to ill health and inequality in South Africa and yet has been largely overlooked. Purpose: This paper focuses on the findings of a recent large study that highlighted emerging issues - namely (i) the high levels of multimorbidity among three key groups - older adults, women, and the wealthy; (ii) discordant and concordant disease clusters among the multimorbid. Research Design: Narrative. Study Sample and Data Collection: Not applicable. Results: We discuss the implications of each emerging issue for health systems policy and practice. Conclusion: Although key policies are identified, many of these policies are not implemented and are therefore not part of routine practice, leaving much space for improvement.
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Affiliation(s)
- Rifqah Abeeda Roomaney
- Burden of Disease Research Unit, South African Medical Research Council, Cape Town, South Africa
- School of Public Health, University of the Western Cape, Cape Town, South Africa
| | - Brian van Wyk
- School of Public Health, University of the Western Cape, Cape Town, South Africa
| | - Victoria Pillay-van Wyk
- Burden of Disease Research Unit, South African Medical Research Council, Cape Town, South Africa
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23
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Shigayeva A, Gcwensa N, Ndlovu CD, Ntumase N, Sabela S, Ohler L, Trivino-Duran L, Kamara EF, Hlophe K, Isaakidis P, Van Cutsem G. Retention on ART and viral suppression among patients in alternative models of differentiated HIV service delivery in KwaZulu-Natal, South Africa. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000336. [PMID: 36962695 PMCID: PMC10021436 DOI: 10.1371/journal.pgph.0000336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 11/10/2022] [Indexed: 06/18/2023]
Abstract
Differentiated models of HIV care (DMOC) aim to improve health care efficiency. We describe outcomes of five DMOC in KwaZulu-Natal, South Africa: facility adherence clubs (facility AC) and community adherence clubs (community AC), community antiretroviral treatment (ART) groups (CAG), spaced fast lane appointments (SFLA), and community pick up points (PuP). This retrospective cohort study included 8241 eligible patients enrolled into DMOC between 1/1/2012 and 31/12/2018. We assessed retention in DMOC and on ART, and viral load suppression (<1000 copies/mL). Kaplan-Meier techniques were applied to describe crude retention. Mixed effects parametric survival models with Weibull distribution and clustering on health center and individual levels were used to assess predictors for ART and DMOC attrition, and VL rebound (≥1000 copies/mL). Overall DMOC retention was 85%, 80%, and 76% at 12, 24 and 36 months. ART retention at 12, 24 and 36 months was 96%, 93%, 90%. Overall incidence rate of VL rebound was 1.9 episodes per 100 person-years. VL rebound rate was 4.9 episodes per 100 person-years among those enrolled in 2012-2015, and 0.8 episodes per 100 person-years among those enrolled in 2016-2018 (RR 0.12; 95% CI, 0.09-0.15, p<0.001). Prevalence of confirmed virological failure was 0.6% (38/6113). Predictors of attrition from DMOC and from ART were male gender, younger age, shorter duration on ART before enrollment. Low level viremia (>200-399 copies/mL) was associated with higher hazards of VL rebound and attrition from ART. Concurrent implementation of several DMOC in a large ART program is feasible and can achieve sustained retention on ART and VL suppression.
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Affiliation(s)
| | - Ntombi Gcwensa
- Médecins Sans Frontières—South Africa, Eshowe, South Africa
| | | | | | | | - Liesbet Ohler
- Médecins Sans Frontières—South Africa, Eshowe, South Africa
| | | | | | | | - Petros Isaakidis
- Southern African Medical Unit, Médecins Sans Frontières, Cape Town, South Africa
- Clinical and Molecular Epidemiology Unit, Department of Hygiene and Epidemiology, University of Ioannina School of Medicine, Ioannina, Greece
| | - Gilles Van Cutsem
- Southern African Medical Unit, Médecins Sans Frontières, Cape Town, South Africa
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, South Africa
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Virologic outcomes after early referral of stable HIV-positive adults initiating ART to community-based adherence clubs in Cape Town, South Africa: A randomised controlled trial. PLoS One 2022; 17:e0277018. [PMCID: PMC9665366 DOI: 10.1371/journal.pone.0277018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 10/17/2022] [Indexed: 11/16/2022] Open
Abstract
Background
Differentiated service delivery (DSD) models are recommended for stable people living with HIV on antiretroviral therapy (ART) but there are few rigorous evaluations of patient outcomes.
Methods
Adherence clubs (ACs) are a form of DSD run by community health workers at community venues with 2–4 monthly ART refills and annual nurse assessments). Clinic-based care involves 2-monthly ART refills and 4-monthly nurse/doctor assessments. We compared virologic outcomes in stable adults randomised to ACs at four months post-ART initiation to those randomised to primary health care (PHC) ART clinics through 12 months on ART in Cape Town, South Africa (NCT03199027). We hypothesised that adults randomised to ACs would be more likely to be virally suppressed at 12 months post-ART initiation, versus adults randomised to continued PHC care. We enrolled consecutive adults on ART for 3–5 months who met local DSD [‘adherence clubs’ (AC)] eligibility (clinically stable, VL<400 copies/mL). The primary outcome was VL<400 copies/mL at 12 months on ART.
Results
Between January 2017 and April 2018, 220 adults were randomised (mean age 35 years; 67% female; median ART duration 18 weeks); 85% and 94% of participants randomised to ACs and PHCs attended their first service visit on schedule respectively. By 12 months on ART, 91% and 93% randomised to ACs and PHCs had a VL<400 copies/mL, respectively. In a binomial model adjusted for age, gender, previous ART use and nadir CD4 cell count, there was no evidence of superiority of ACs compared to clinic-based care (RD, -2.42%; 95% CI, -11.23 to 6.38). Findings were consistent when examining the outcome at a threshold of VL <1000 copies/mL.
Conclusion
Stable adults referred to DSDs at 4 months post-ART initiation had comparable virologic outcomes at 12 months on ART versus PHC clinics, with no evidence of superiority. Further research on long-term outcomes is required.
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Factors associated with ART adherence among HIV-positive adherence club members in Ekurhuleni Metropolitan Municipality, South Africa: A cross-sectional study. PLoS One 2022; 17:e0277039. [PMID: 36318541 PMCID: PMC9624407 DOI: 10.1371/journal.pone.0277039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 10/19/2022] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND HIV is a leading cause of morbidity and mortality in South Africa that can be managed using antiretroviral therapy (ART). Adherence clubs are interventions that have been introduced to decentralize ART to improve ART adherence and provide social support for club members. However, ART adherence can be suboptimal even among adherence club members. AIM This study aimed to determine the factors affecting ART adherence among people living with HIV/AIDS (PLWHA) attending adherence clubs in Ekurhuleni Metropolitan Municipality. METHODS A cross-sectional study was conducted. Ordinal logistic regression was used in univariable and multivariable analyses to determine factors significantly associated with adherence scores. Factors included in the final model were age, comorbidity, ART regimen and club membership duration. RESULTS The records of 730 participants were analysed. After adjusting for age, participants with comorbidities were half as likely to report high ART adherence scores compared to participants without comorbidities (AOR = 0.5, 95% CI: 0.3-0.8, p = 0.005). The adjusted odds of reporting high levels of adherence among participants on cART were 1.8 times those on a single tablet regimen (AOR = 1.8, 95% CI: 1.0-3.2; p = 0.033). There was a 20% reduction in the adjusted odds of reporting high ART adherence for each additional year of adherence club membership (AOR = 0.8, 95% CI: 0.8-0.9, p<0.001). CONCLUSION Increasing years spent as adherence club members, single tablet ART regimens and the presence of comorbidities were all significantly associated with low ART adherence among study participants. Regular assessment of the quality of counselling sessions for ART adherence club members and questionnaires for early screening of treatment fatigue have been suggested as tools for improved adherence in ART adherence club settings.
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Leveraging routine data in impact evaluation: Understanding data systems in primary healthcare prior to a matched cluster-randomised evaluation of adherence guidelines in South Africa. S Afr Med J 2022; 112:819-827. [PMID: 36472333 DOI: 10.7196/samj.2022.v112i10.14909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND An essential part of providing high-quality patient care and a means of efficiently conducting research studies relies upon high-quality routinely collected medical information. OBJECTIVES To describe the registers, paper records and databases used in a sample of primary healthcare clinics in South Africa (SA) with the view to conduct an impact evaluation using routine data. METHODS Between October 2015 and December 2015, we collected information on the presence, quality and completeness of registers, clinical stationery and databases at 24 public health facilities in SA. We describe each register and type of clinical stationery we encountered, their primary uses, and the quality of completion. We also mapped the ideal flow of data through a site to better understand how its data collection works. RESULTS We identified 13 registers (9 standard, 4 non-standard), 5 types of stationery and 4 databases as sources of medical information within a site. Not all clinics used all the standardised registers, and in those that did, registers were kept in various degrees of completeness: a common problem was inconsistent recording of folder numbers. The quality of patient stationery was generally high, with only the chronic patient record being considered of varied quality. The TIER.Net database had high-quality information on key variables, but national identification (ID) number was incompletely captured (42% complete). Very few evaluation sites used electronic data collection systems for conditions other than HIV/AIDS. CONCLUSION Registers, databases and clinical stationery were not implemented or completed consistently across the 24 evaluation sites. For those considering using routinely collected data for research and evaluation purposes, we would recommend a thorough review of clinic data collection systems for both quality and completeness before considering them to be a reliable data source.
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Kuo AP, Roche SD, Mugambi ML, Pintye J, Baeten JM, Bukusi E, Ngure K, Stergachis A, Ortblad KF. The effectiveness, feasibility and acceptability of HIV service delivery at private pharmacies in sub-Saharan Africa: a scoping review. J Int AIDS Soc 2022; 25:e26027. [PMID: 36285619 PMCID: PMC9597376 DOI: 10.1002/jia2.26027] [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: 04/18/2022] [Accepted: 09/28/2022] [Indexed: 11/05/2022] Open
Abstract
INTRODUCTION Private pharmacies are an understudied setting for differentiated delivery of HIV services that may address barriers to clinic-delivered services, such as stigma and long wait times. To understand the potential for pharmacy-delivered HIV services in sub-Saharan Africa, we conducted a scoping review of the published and grey literature. METHODS Using a modified Cochrane approach, we searched electronic databases through March 2022 and HIV conference abstracts in the past 5 years for studies that: (1) focused on the delivery of HIV testing, antiretroviral therapy (ART) and/or pre-exposure prophylaxis (PrEP) at private pharmacies in sub-Saharan Africa; (2) reported on effectiveness outcomes (e.g. HIV incidence) or implementation outcomes, specifically feasibility and/or acceptability; and (3) were published in English. Two authors identified studies and extracted data on study setting, population, design, outcomes and findings by HIV service type. RESULTS AND DISCUSSION Our search identified 1646 studies. After screening and review, we included 28 studies: seven on HIV testing, nine on ART delivery and 12 on PrEP delivery. Most studies (n = 16) were conducted in East Africa, primarily in Kenya. Only two studies evaluated effectiveness outcomes; the majority (n = 26) reported on feasibility and/or acceptability outcomes. The limited effectiveness data (n = 2 randomized trials) suggest that pharmacy-delivered HIV services can increase demand and result in comparable clinical outcomes (e.g. viral load suppression) to standard-of-care clinic-based models. Studies assessing implementation outcomes found actual and hypothetical models of pharmacy-delivered HIV services to be largely feasible (e.g. high initiation and continuation) and acceptable (e.g. preferable to facility-based models and high willingness to pay/provide) among stakeholders, providers and clients. Potential barriers to implementation included a lack of pharmacy provider training on HIV service delivery, costs to clients and providers, and perceived low quality of care. CONCLUSIONS The current evidence suggests that pharmacy-delivered HIV services may be feasible to implement and acceptable to clients and providers in parts of sub-Saharan Africa. However, limited evidence outside East Africa exists, as does limited evidence on the effectiveness of and costs associated with pharmacy-delivered HIV services. More research of this nature is needed to inform the scale-up of this new differentiated service delivery model throughout the region.
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Affiliation(s)
- Alexandra P. Kuo
- Department of PharmacyUniversity of WashingtonSeattleWashingtonUSA
| | - Stephanie D. Roche
- Public Health Sciences DivisionFred Hutchinson Cancer CenterSeattleWashingtonUSA
| | | | - Jillian Pintye
- School of NursingUniversity of WashingtonSeattleWashingtonUSA
| | - Jared M. Baeten
- Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA
- School of NursingUniversity of WashingtonSeattleWashingtonUSA
- Department of EpidemiologyUniversity of WashingtonSeattleWashingtonUSA
- Department of MedicineUniversity of WashingtonSeattleWashingtonUSA
- Gilead SciencesFoster CityCaliforniaUSA
| | - Elizabeth Bukusi
- Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA
- Centre for Microbiology ResearchKenya Medical Research InstituteNairobiKenya
- Department of Obstetrics and GynecologyUniversity of WashingtonSeattleWashingtonUSA
| | - Kenneth Ngure
- Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA
- Department of Community HealthJomo Kenyatta University of Agriculture and TechnologyNairobiKenya
| | - Andy Stergachis
- Department of PharmacyUniversity of WashingtonSeattleWashingtonUSA
- Department of Global HealthUniversity of WashingtonSeattleWashingtonUSA
| | - Katrina F. Ortblad
- Public Health Sciences DivisionFred Hutchinson Cancer CenterSeattleWashingtonUSA
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Maskew M, Technau K, Davies MA, Vreeman R, Fox MP. Adolescent retention in HIV care within differentiated service-delivery models in sub-Saharan Africa. Lancet HIV 2022; 9:e726-e734. [PMID: 36088915 PMCID: PMC9927242 DOI: 10.1016/s2352-3018(22)00137-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 04/11/2022] [Accepted: 05/06/2022] [Indexed: 02/05/2023]
Abstract
Adolescents and young people living with HIV are at risk of disengaging from HIV care at all stages of the care cascade. Differentiated models of care offer simplified HIV-service delivery options in the hope of improving treatment outcomes, including retention on antiretroviral therapy. However, it remains unclear how successful and widespread these models are for adolescents in sub-Saharan Africa, where the burden of HIV is the greatest. Very few differentiated models of care specifically targeted to adolescents can be found and this priority group are currently ineligible from several models that exist. Where differentiated care has been made available to adolescents, data on the implementation and effectiveness of these interventions remain scarce. Despite this scarcity of evidence on the effectiveness of differentiated care among adolescent populations, several interventions, particularly community-based groups with peer navigators or supporters, might have potential to increase the reach, effectiveness, and adoption of differentiated care in adolescent HIV-care programmes.
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Affiliation(s)
- Mhairi Maskew
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa.
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Christ B, van Dijk JH, Nyandoro TY, Reichmuth ML, Kunzekwenyika C, Chammartin F, Egger M, Wringe A, Ballif M. Availability and experiences of differentiated antiretroviral therapy delivery at HIV care facilities in rural Zimbabwe: a mixed-method study. J Int AIDS Soc 2022; 25:e25944. [PMID: 36008925 PMCID: PMC9411726 DOI: 10.1002/jia2.25944] [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: 06/28/2021] [Accepted: 05/20/2022] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION Zimbabwe adopted differentiated HIV care policies in 2015 to promote client-centred care and relieve strain on health facilities. We examined the availability, experiences and perceptions of differentiated antiretroviral therapy (ART) delivery in rural Zimbabwe following the policy adoption. METHODS We undertook a cross-sectional mixed methods study in all the 26 facilities providing HIV care in a rural district in Zimbabwe. We collected quantitative data about ART delivery and visit durations from 31 healthcare providers and a purposive stratified sample of 378 clients obtaining ART either through routine care or differentiated ART delivery models. We performed 26 semi-structured interviews among healthcare providers and seven focus group discussions (FGDs) among clients to elicit their perceptions and experiences of ART delivery. Data were collected in 2019, with one follow-up FGD in 2021. We analysed the transcripts thematically, with inductive coding, to identify emerging themes. RESULTS Twenty facilities (77%) offered at least one differentiated ART delivery models, including community ART refill groups (CARGs; 13 facilities, 50%), fast-track refill (8, 31%), family refill (6, 23%) or club refill (1, 4%). Thirteen facilities (50%) offered only one model. The median visit duration was 28 minutes (interquartile range [IQR]: 16-62). Participants in fast-track had the shortest visit durations (18 minutes, IQR: 11-24). Confidentiality and disclosure of HIV status, travelling long distances, travel costs and waiting times were the main issues influencing clients' views on differentiated ART delivery. Fast-track refill was perceived as the preferred model of clients for its limited involuntary disclosure and efficiency. In contrast, group- and community-based refill models reduced travel costs but were felt to be associated with involuntary disclosure of HIV status, which could discourage clients. Healthcare providers also experienced an additional workload when offering facility-based group models, such as CARGs. CONCLUSIONS Differentiated ART delivery models were widely available in this rural setting, but most facilities did not offer a choice of models to address clients' diverse preferences. A minority offered fast-track refills, although this model was often mentioned as desirable. Confidentiality, travel expenses and client waiting times are key elements to consider when planning and rolling out differentiated HIV care.
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Affiliation(s)
- Benedikt Christ
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | | | | | - Martina L Reichmuth
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | | | | | - Matthias Egger
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland.,Centre for Infectious Disease Research and Epidemiology, University of Cape Town, Cape Town, South Africa.,Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Alison Wringe
- London School of Hygiene and Tropical Medicine, London, UK
| | - Marie Ballif
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
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Leslie HH, West R, Twine R, Masilela N, Steward WT, Kahn K, Lippman SA. Measuring Organizational Readiness for Implementing Change in Primary Care Facilities in Rural Bushbuckridge, South Africa. Int J Health Policy Manag 2022; 11:912-918. [PMID: 33300775 PMCID: PMC9808169 DOI: 10.34172/ijhpm.2020.223] [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: 03/09/2020] [Accepted: 10/28/2020] [Indexed: 01/12/2023] Open
Abstract
Meaningful gains in health outcomes require successful implementation of evidence-based interventions. Organizations such as health facilities must be ready to implement efficacious interventions, but tools to measure organizational readiness have rarely been validated outside of high-income settings. We conducted a pilot study of the organizational readiness to implement change (ORIC) measure in public primary care facilities serving Bushbuckridge Municipality in South Africa in early 2019. We administered the 10-item ORIC to 54 nurses and lay counsellors in 9 facilities to gauge readiness to implement the national Central Chronic Medicine Dispensing and Distribution (CCMDD) programme intended to declutter busy health facilities. We used exploratory factor analysis (EFA) to identify factor structure. We used Cronbach alpha and intraclass correlation (ICC) to assess reliability at the individual and facility levels. To assess validity, we drew on existing data from routine clinic monitoring and a 2018 quality assessment to test the correlation of ORIC with facility resources, value of CCMDD programme, and better programme uptake and service quality. Six items from the ORIC loaded onto a single factor with Cronbach's alpha of 0.82 and ICC of 0.23. While facility ORIC score was not correlated with implementation of CCMDD, higher scores were correlated with facility resources, perceived value of the CCMDD program, patient satisfaction with wait time, and greater linkage to care following positive HIV testing. The study is limited by measuring ORIC after programme implementation. The findings support the relevance of ORIC, but identify a need for greater adaptation and validation of the measure.
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Affiliation(s)
- Hannah H. Leslie
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Rebecca West
- Division of Prevention Science, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
- Boston University School of Public Health, Boston, MA, USA
| | - Rhian Twine
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Nkosinathi Masilela
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Wayne T. Steward
- Division of Prevention Science, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Kathleen Kahn
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Sheri A. Lippman
- Division of Prevention Science, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Audet CM, Pettapiece-Phillips M, Tian Y, Shepherd BE, Vermund SH, Salato J. "If it weren't for my traditional healer, I would be dead": Engaging traditional healers to support people living with HIV in rural Mozambique. PLoS One 2022; 17:e0270565. [PMID: 35763519 PMCID: PMC9239464 DOI: 10.1371/journal.pone.0270565] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 06/13/2022] [Indexed: 11/29/2022] Open
Abstract
Across rural sub-Saharan Africa, people living with HIV (PLHIV) commonly seek out treatment from traditional healers. We report on the clinical outcomes of a community health worker intervention adapted for traditional healers with insight into our results from qualitative interviews. We employed a pre-post intervention study design and used sequential mixed methods to assess the impact of a traditional healer support worker intervention in Zambézia province, Mozambique. After receiving a positive test result, 276 participants who were newly enrolled in HIV treatment and were interested in receiving home-based support from a traditional healer were recruited into the study. Those who enrolled from February 2016 to August 2016 received standard of care services, while those who enrolled from June 2017 to May 2018 received support from a traditional healer. We conducted interviews among healers and participants to gain insight into fidelity of study activities, barriers to support, and program improvement. Medication possession ratio at home (based on pharmacy pick-up dates) was not significantly different between pre- and post-intervention participants (0.80 in the pre-intervention group compared to 0.79 in the post-intervention group; p = 0.96). Participants reported receiving educational and psychosocial support from healers. Healers adapted their support protocol to initiate directly observed therapy among participants with poor adherence. Traditional healers can provide community-based psychosocial support, education, directly observed therapy, and disclosure assistance for PLHIV. Multiple factors may hinder patients' desire and ability to remain adherent to treatment, including poverty, confusion about medication side effects, and frustration with wait times at the health facility.
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Affiliation(s)
- Carolyn M. Audet
- Department of Health Policy, Vanderbilt University, Nashville, TN, United States of America
| | | | - Yuqi Tian
- Department of Biostatistics, Vanderbilt University, Nashville, TN, United States of America
| | - Bryan E. Shepherd
- Department of Biostatistics, Vanderbilt University, Nashville, TN, United States of America
| | - Sten H. Vermund
- School of Public Health, Yale University, New Haven, CT, United States of America
| | - Jose Salato
- Friends in Global Health, Quelimane, Mozambique
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Okere NE, Meta J, Maokola W, Martelli G, van Praag E, Naniche D, Gomez GB, Pozniak A, Rinke de Wit T, de Klerk J, Hermans S. Quality of care in a differentiated HIV service delivery intervention in Tanzania: A mixed-methods study. PLoS One 2022; 17:e0265307. [PMID: 35290989 PMCID: PMC8923447 DOI: 10.1371/journal.pone.0265307] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 02/28/2022] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Differentiated service delivery (DSD) offers benefits to people living with HIV (improved access, peer support), and the health system (clinic decongestion, efficient service delivery). ART clubs, 15-30 clients who usually meet within the community, are one of the most common DSD options. However, evidence about the quality of care (QoC) delivered in ART clubs is still limited. MATERIALS AND METHODS We conducted a concurrent triangulation mixed-methods study as part of the Test & Treat project in northwest Tanzania. We surveyed QoC among stable clients and health care workers (HCW) comparing between clinics and clubs. Using a Donabedian framework we structured the analysis into three levels of assessment: structure (staff, equipment, supplies, venue), processes (time-spent, screenings, information, HCW-attitude), and outcomes (viral load, CD4 count, retention, self-worth). RESULTS We surveyed 629 clients (40% in club) and conducted eight focus group discussions, while 24 HCW (25% in club) were surveyed and 22 individual interviews were conducted. Quantitative results revealed that in terms of structure, clubs fared better than clinics except for perceived adequacy of service delivery venue (94.4% vs 50.0%, p = 0.013). For processes, time spent receiving care was significantly more in clinics than clubs (119.9 vs 49.9 minutes). Regarding outcomes, retention was higher in the clubs (97.6% vs 100%), while the proportion of clients with recent viral load <50 copies/ml was higher in clinics (100% vs 94.4%). Qualitative results indicated that quality care was perceived similarly among clients in clinics and clubs but for different reasons. Clinics were generally perceived as places with expertise and clubs as efficient places with peer support and empathy. In describing QoC, HCW emphasized structure-related attributes while clients focused on processes. Outcomes-related themes such as improved client health status, self-worth, and confidentiality were similarly perceived across clients and HCW. CONCLUSION We found better structure and process of care in clubs than clinics with comparable outcomes. While QoC was perceived similarly in clinics and clubs, its meaning was understood differently between clients. DSD catered to the individual needs of clients, either technical care in the clinic or proximate and social care in the club. Our findings highlight that both clinic and DSD care are required as many elements of QoC were individually perceived.
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Affiliation(s)
- Nwanneka Ebelechukwu Okere
- Amsterdam Institute for Global Health and Development (AIGHD), Department of Global Health, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
- * E-mail:
| | - Judith Meta
- Amsterdam Institute for Global Health and Development (AIGHD), Department of Global Health, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Werner Maokola
- Department of Strategic Information, National AIDS Control Programme, Dodoma, Tanzania
| | | | - Eric van Praag
- Amsterdam Institute for Global Health and Development (AIGHD), Department of Global Health, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Denise Naniche
- ISGlobal -Barcelona Institute for Global Health, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Gabriela B. Gomez
- Department of Global Health and Development London School of Health and Tropical Medicine London, London, United Kingdom
| | - Anton Pozniak
- Chelsea and Westminster Hospital NHS Foundation Trust, and LSHTM London, London, United Kingdom
| | - Tobias Rinke de Wit
- Amsterdam Institute for Global Health and Development (AIGHD), Department of Global Health, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Josien de Klerk
- Amsterdam Institute for Global Health and Development (AIGHD), Department of Global Health, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Sabine Hermans
- Amsterdam Institute for Global Health and Development (AIGHD), Department of Global Health, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
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Duffy M, Madevu-Matson C, Posner JE, Zwick H, Sharer M, Powell AM. Systematic review: Development of a person-centered care framework within the context of HIV treatment settings in sub-Saharan Africa. Trop Med Int Health 2022; 27:479-493. [PMID: 35316549 PMCID: PMC9324124 DOI: 10.1111/tmi.13746] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Objectives Person‐centred care (PCC) meets the needs of individuals by increasing convenience, providing supportive and culturally appropriate services to diverse populations, and engaging families, communities, and stakeholders in planning and provision of care. While the evidence demonstrates that PCC approaches can lead to clinical improvements across the HIV care continuum, it is not yet well defined in the context of HIV service delivery. Methods A systematic review was conducted to define PCC practices for HIV treatment services in health facilities in sub‐Saharan Africa. Data synthesis led to the development of a PCC framework including domain and sub‐domain development. The study team used the Effective Public Health Project Practice tool for quantitative studies to assess the quality of the included studies. Results Thirty‐one studies from 12 countries met the inclusion criteria, including 56,586 study participants (females 42%–100% and males 0%—58%), resulting in three major domains and 11 sub‐domains. These include staffing (sub‐domains of composition, availability, and competency); service delivery standards (sub‐domains of client feedback mechanisms; service efficiency and integration; convenience and access; and digital health worker support tools); and direct client support services (sub‐domains of psychosocial services, logistics support, client‐agency, and digital client support tools). Twenty‐five of the person‐centred interventions within these domains resulted in improvements in linkage to care, treatment retention, and/or viral suppression. Conclusions The PCC framework can help to provide a more consistent classification of HIV treatment interventions and will support improved assessment of these interventions to ensure that people receive personalised care.
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Affiliation(s)
- Malia Duffy
- International Division, John Snow, Inc., Boston, Massachusetts, USA.,Public Health, Saint Ambrose University, Davenport, Iowa, USA
| | | | - Jessica E Posner
- International Division, John Snow, Inc., Boston, Massachusetts, USA
| | - Hana Zwick
- International Division, John Snow, Inc., Boston, Massachusetts, USA.,Global Health Institute, Duke University, Durham, North Carolina, USA
| | - Melissa Sharer
- International Division, John Snow, Inc., Boston, Massachusetts, USA.,Public Health, Saint Ambrose University, Davenport, Iowa, USA
| | - Antonia M Powell
- International Division, John Snow, Inc., Boston, Massachusetts, USA
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Roomaney RA, van Wyk B, Cois A, Pillay-van Wyk V. Multimorbidity Patterns in a National HIV Survey of South African Youth and Adults. Front Public Health 2022; 10:862993. [PMID: 35444991 PMCID: PMC9015099 DOI: 10.3389/fpubh.2022.862993] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 03/14/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction Information pertaining to multimorbidity is frequently informed by studies from high income countries and it is unclear how these findings relate to low and middle income countries, where the burden of infectious disease is high. South Africa has a quadruple burden of disease which includes a high HIV prevalence and a growing burden of non-communicable diseases. This study aimed to analyse the prevalence and patterns (disease classes or clusters) of multimorbidity in South Africa. Methods A secondary analysis of individuals over the age of 15 years who participated in the Fifth South African National HIV Prevalence, Incidence, Behavior and Communication Survey, 2017 (SABSSM 2017) was done. Six disease conditions were identified in the analysis (cancer, diabetes, heart disease, hypertension/high blood pressure, tuberculosis, and HIV). Chi-square tests were used to test for the differences in disease prevalence by sex. Common disease patterns were identified using a latent class analysis. Results The sample included 27,896 participants, of which 1,837 had comorbidity or multimorbidity. When taking population-weighting into account, multimorbidity was present in 5.9% (95% CI: 5.4–6.4) of the population The prevalence of multimorbidity tended to be higher among females and increased with age, reaching 21.9% in the oldest age group (70+). The analyses identified seven distinct disease classes in the population. The largest class was “Diabetes and Hypertension” (36.3%), followed by “HIV and Hypertension” (31.0%), and “Heart disease and Hypertension” (14.5%). The four smaller classes were: “HIV, Diabetes, and Heart disease” (6.9%), “TB and HIV” (6.3%), “Hypertension, TB, and Cancer” (2.8%), and “All diseases except HIV” (2.2%). Conclusion As the South African population continues to age, the prevalence of multimorbidity is likely to increase which will further impact the health care system. The prevalence of multimorbidity in the population was relatively low but reached up to 20% in the oldest age groups. The largest disease cluster was the combination of diabetes and hypertension; followed by HIV and hypertension. The gains in improving adherence to antiretrovirals amongst treatment-experienced people living with HIV, should be expanded to include compliance with lifestyle/behavioral modifications to blood pressure and glucose control, as well as adherence to anti-hypertension and anti-diabetic medication. There is an urgent need to improve the early diagnosis and treatment of disease in the South African population.
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Affiliation(s)
- Rifqah Abeeda Roomaney
- Burden of Disease Research Unit, South African Medical Research Council, Cape Town, South Africa.,School of Public Health, University of the Western Cape, Cape Town, South Africa
| | - Brian van Wyk
- School of Public Health, University of the Western Cape, Cape Town, South Africa
| | - Annibale Cois
- Burden of Disease Research Unit, South African Medical Research Council, Cape Town, South Africa.,Division of Health Systems and Public Health, Department of Global Health, University of Stellenbosch, Stellenbosch, South Africa
| | - Victoria Pillay-van Wyk
- Burden of Disease Research Unit, South African Medical Research Council, Cape Town, South Africa
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Le Tourneau N, Germann A, Thompson RR, Ford N, Schwartz S, Beres L, Mody A, Baral S, Geng EH, Eshun-Wilson I. Evaluation of HIV treatment outcomes with reduced frequency of clinical encounters and antiretroviral treatment refills: A systematic review and meta-analysis. PLoS Med 2022; 19:e1003959. [PMID: 35316272 PMCID: PMC8982898 DOI: 10.1371/journal.pmed.1003959] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 04/05/2022] [Accepted: 03/04/2022] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Global HIV treatment programs have sought to lengthen the interval between clinical encounters for people living with HIV (PLWH) who are established on antiretroviral treatment (ART) to reduce the burden of seeking care and to decongest health facilities. The overall effect of reduced visit frequency on HIV treatment outcomes is however unknown. We conducted a systematic review and meta-analysis to evaluate the effect of implementation strategies that reduce the frequency of clinical appointments and ART refills for PLWH established on ART. METHODS AND FINDINGS We searched databases between 1 January 2010 and 9 November 2021 to identify randomized controlled trials (RCTs) and observational studies that compared reduced (6- to 12-monthly) clinical consultation or ART refill appointment frequency to 3- to 6-monthly appointments for patients established on ART. We assessed methodological quality and real-world relevance, and used Mantel-Haenszel methods to generate pooled risk ratios (RRs) with 95% confidence intervals for retention, viral suppression, and mortality. We evaluated heterogeneity quantitatively and qualitatively, and overall evidence certainty using GRADE. Searches yielded 3,955 records, resulting in 10 studies (6 RCTs, 3 observational studies, and 1 study contributing observational and RCT data) representing 15 intervention arms with 33,599 adults (≥16 years) in 8 sub-Saharan African countries. Reduced frequency clinical consultations occurred at health facilities, while reduced frequency ART refills were delivered through facility or community pharmacies and adherence groups. Studies were highly pragmatic, except for some study settings and resources used in RCTs. Among studies comparing reduced clinical consultation frequency (6- or 12-monthly) to 3-monthly consultations, there appeared to be no difference in retention (RR 1.01, 95% CI 0.97-1.04, p = 0.682, 8 studies, low certainty), and this finding was consistent across 6- and 12-monthly consultation intervals and delivery strategies. Viral suppression effect estimates were markedly influenced by under-ascertainment of viral load outcomes in intervention arms, resulting in inconclusive evidence. There was similarly insufficient evidence to draw conclusions on mortality (RR 1.12, 95% CI 0.75-1.66, p = 0.592, 6 studies, very low certainty). For ART refill frequency, there appeared to be little to no difference in retention (RR 1.01, 95% CI 0.98-1.06, p = 0.473, 4 RCTs, moderate certainty) or mortality (RR 1.45, 95% CI 0.63-3.35, p = 0.382, 4 RCTs, low certainty) between 6-monthly and 3-monthly visits. Similar to the analysis for clinical consultations, although viral suppression appeared to be better in 3-monthly arms, effect estimates were markedly influence by under-ascertainment of viral load outcomes in intervention arms, resulting in overall inclusive evidence. This systematic review was limited by the small number of studies available to compare 12- versus 6-monthly clinical consultations, insufficient data to compare implementation strategies, and lack of evidence for children, key populations, and low- and middle-income countries outside of sub-Saharan Africa. CONCLUSIONS Based on this synthesis, extending clinical consultation intervals to 6 or 12 months and ART dispensing intervals to 6 months appears to result in similar retention to 3-month intervals, with less robust conclusions for viral suppression and mortality. Future research should ensure complete viral load outcome ascertainment, as well as explore mechanisms of effect, outcomes in other populations, and optimum delivery and monitoring strategies to ensure widespread applicability of reduced frequency visits across settings.
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Affiliation(s)
- Noelle Le Tourneau
- Division of Infectious Diseases, School of Medicine, Washington University in St. Louis, Saint Louis, Missouri, United States of America
- * E-mail:
| | - Ashley Germann
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Ryan R. Thompson
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Nathan Ford
- Department of Global HIV, Hepatitis and Sexually Transmitted Diseases, World Health Organization, Geneva, Switzerland
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Sheree Schwartz
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Laura Beres
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Aaloke Mody
- Division of Infectious Diseases, School of Medicine, Washington University in St. Louis, Saint Louis, Missouri, United States of America
| | - Stefan Baral
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Elvin H. Geng
- Division of Infectious Diseases, School of Medicine, Washington University in St. Louis, Saint Louis, Missouri, United States of America
- Center for Dissemination and Implementation, Institute for Public Health, Washington University in St. Louis, Saint Louis, Missouri, United States of America
| | - Ingrid Eshun-Wilson
- Division of Infectious Diseases, School of Medicine, Washington University in St. Louis, Saint Louis, Missouri, United States of America
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Bassett IV, Yan J, Govere S, Khumalo A, Ngobese N, Shazi Z, Nzuza M, Bunda BA, Wara NJ, Stuckwisch A, Zionts D, Dube N, Tshabalala S, Bogart LM, Parker RA. Uptake of community‐ versus clinic‐based antiretroviral therapy dispensing in the Central Chronic Medication Dispensing and Distribution program in South Africa. J Int AIDS Soc 2022; 25:e25877. [PMID: 35077611 PMCID: PMC8789242 DOI: 10.1002/jia2.25877] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 12/28/2021] [Indexed: 12/30/2022] Open
Abstract
Introduction South Africa's government‐led Central Chronic Medication Dispensing and Distribution (CCMDD) program offers people living with HIV the option to collect antiretroviral therapy at their choice of community‐ or clinic‐based pick‐up points intended to increase convenience and decongest clinics. To understand CCMDD pick‐up point use among people living with HIV, we evaluated factors associated with uptake of a community‐ versus clinic‐based pick‐up point at CCMDD enrolment. Methods We collected baseline data from October 2018 to March 2020 on adults (≥18 years) who met CCMDD clinical eligibility criteria (non‐pregnant, on antiretroviral therapy for ≥1 year and virologically suppressed) as part of an observational cohort in seven public clinics in KwaZulu‐Natal. We identified factors associated with community‐based pick‐up point uptake and fit a multivariable logistic regression model, including age, gender, employment status, self‐perceived barriers to care, self‐efficacy, HIV‐related discrimination, and perceived benefits and challenges of CCMDD. Results and Discussion Among 1521 participants, 67% were females, with median age 36 years (IQR 30–44). Uptake of a community‐based pick‐up point was associated with younger age (aOR 1.18 per 10‐year decrease, 95% CI 1.05–1.33), being employed ≥40 hours per week (aOR 1.42, 95% CI 1.10–1.83) versus being unemployed, no self‐perceived barriers to care (aOR 1.42, 95% CI 1.09–1.86) and scoring between 36 and 39 (aOR 1.44, 95% CI 1.03–2.01) or 40 (aOR 1.91, 95% CI 1.39–2.63) versus 10–35 on the self‐efficacy scale, where higher scores indicate greater self‐efficacy. Additional factors included more convenient pick‐up point location (aOR 2.32, 95% CI 1.77–3.04) or hours (aOR 5.09, 95% CI 3.71–6.98) as perceived benefits of CCMDD, and lack of in‐clinic follow‐up after a missed collection date as a perceived challenge of CCMDD (aOR 4.37, 95% CI 2.30–8.31). Conclusions Uptake of community‐based pick‐up was associated with younger age, full‐time employment, and systemic and structural factors of living with HIV (no self‐perceived barriers to care and high self‐efficacy), as well as perceptions of CCMDD (convenient pick‐up point location and hours, lack of in‐clinic follow‐up). Strategies to facilitate community‐based pick‐up point uptake should be tailored to patients’ age, employment, self‐perceived barriers to care and self‐efficacy to maximize the impact of CCMDD in decongesting clinics.
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Affiliation(s)
- Ingrid V. Bassett
- Massachusetts General Hospital Division of Infectious Diseases Boston Massachusetts USA
- Massachusetts General Hospital Medical Practice Evaluation Center Boston Massachusetts USA
- Center for AIDS Research (CFAR) Harvard University Boston Massachusetts USA
- Harvard Medical School Boston Massachusetts USA
| | - Joyce Yan
- Massachusetts General Hospital Biostatistics Center Boston Massachusetts USA
| | | | | | | | | | | | - Bridget A. Bunda
- Massachusetts General Hospital Medical Practice Evaluation Center Boston Massachusetts USA
| | - Nafisa J. Wara
- Massachusetts General Hospital Medical Practice Evaluation Center Boston Massachusetts USA
| | - Ashley Stuckwisch
- Massachusetts General Hospital Medical Practice Evaluation Center Boston Massachusetts USA
| | - Dani Zionts
- Massachusetts General Hospital Medical Practice Evaluation Center Boston Massachusetts USA
| | | | - Sandile Tshabalala
- South Africa Department of Health Province of KwaZulu‐Natal South Africa
| | | | - Robert A. Parker
- Center for AIDS Research (CFAR) Harvard University Boston Massachusetts USA
- Harvard Medical School Boston Massachusetts USA
- Massachusetts General Hospital Biostatistics Center Boston Massachusetts USA
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Labisi TO, Podany AT, Fadul NA, Coleman JD, King KM. Factors associated with viral suppression among cisgender women living with human immunodeficiency virus in the United States: An integrative review. WOMEN'S HEALTH (LONDON, ENGLAND) 2022; 18:17455057221092267. [PMID: 35435055 PMCID: PMC9019389 DOI: 10.1177/17455057221092267] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Women account for 23% of new human immunodeficiency virus diagnoses in the United States, yet remain understudied. Adherence to antiretroviral therapy and consequent viral suppression are keys to preventing human immunodeficiency virus transmission, reducing risk of drug resistance, and improving health outcomes. OBJECTIVES This review identified and synthesized peer-reviewed studies in the United States describing factors associated with viral suppression among cisgender women living with human immunodeficiency virus. METHODS We searched five databases: Cumulative Index to Nursing and Allied Health (CINAHL), PubMed, Embase, Scopus, and PsycINFO, and reported the findings using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Eligible studies included: (1) peer-reviewed English-language articles published since 2010; (2) includes only cisgender women; (3) participants were at least 18 years of age; (4) reported metrics on viral loads; and (5) conducted in the United States. RESULTS Fourteen studies in total were reviewed. Eight studies had adult women living with human immunodeficiency virus, four recruited only pregnant women, and two included only racial minority women. The most commonly reported factors negatively associated with viral suppression were substance use (n = 4), followed by availability of health insurance, financial constraint, complexity of human immunodeficiency virus treatment regimen (n = 3), and intimate partner violence (n = 2). Other factors were depression, race, and age. In addition, all four studies that included only pregnant women reported early human immunodeficiency virus care engagement as a significant predictor of low viral loads pre- and post-partum. CONCLUSION Substance use, financial constraint, lack of health insurance, human immunodeficiency virus treatment regimen type, intimate partner violence, and late human immunodeficiency virus care pre-post pregnancy were the most common factors negatively associated with viral suppression. There is a paucity of data on viral suppression factors related to transgender and rural populations. More human immunodeficiency virus research is needed to explore factors associated with human immunodeficiency virus treatment outcomes in transgender women and cisgender women in rural U.S. regions.
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Affiliation(s)
- Titilola O Labisi
- Department of Health Promotion and Disease Prevention, College of Public Health, University of Nebraska Medical Center, Omaha, NE, USA
| | - Anthony T Podany
- College of Pharmacy, University of Nebraska Medical Center, Omaha, NE, USA
| | - Nada A Fadul
- College of Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Jason D Coleman
- School of Health and Kinesiology, University of Nebraska Omaha, Omaha, NE, USA
| | - Keyonna M King
- Department of Health Promotion and Disease Prevention, College of Public Health, University of Nebraska Medical Center, Omaha, NE, USA
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Gray KL, Kiazolu M, Jones J, Konstantinova A, Zawolo JSW, Gray WMH, Walker NF, Garbo JT, Caldwell S, Odo M, Bhadelia N, DeMarco J, Skrip LA. Liberia adherence and loss-to-follow-up in HIV and AIDS care and treatment: A retrospective cohort of adolescents and adults from 2016-2019. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000198. [PMID: 36962289 PMCID: PMC10021315 DOI: 10.1371/journal.pgph.0000198] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 02/23/2022] [Indexed: 11/18/2022]
Abstract
Antiretroviral therapy (ART) is a lifesaving intervention for people living with HIV infection, reducing morbidity and mortality; it is likewise essential to reducing transmission. The "Treat all" strategy recommended by the World Health Organization has dramatically increased ART eligibility and improved access. However, retaining patients on ART has been a major challenge for many national programs in low- and middle-income settings, despite actionable local policies and ambitious targets. To estimate retention of patients along the HIV care cascade in Liberia, and identify factors associated with loss-to-follow-up (LTFU), death, and suboptimal treatment adherence, we conducted a nationwide retrospective cohort study utilizing facility and patient-level records. Patients aged ≥15 years, from 28 facilities who were first registered in HIV care from January 2016 -December 2017 were included. We used Cox proportional hazard models to explore associations between demographic and clinical factors and the outcomes of LTFU and death, and a multinomial logistic regression model to investigate factors associated with suboptimal treatment adherence. Among the 4185 records assessed, 27.4% (n = 1145) were males and the median age of the cohort was 37 (IQR: 30-45) years. At 24 months of follow-up, 41.8% (n = 1751) of patients were LTFU, 6.6% (n = 278) died, 0.5% (n = 21) stopped treatment, 3% (n = 127) transferred to another facility and 47.9% (n = 2008) were retained in care and treatment. The incidence of LTFU was 46.0 (95% CI: 40.8-51.6) per 100 person-years. Relative to patients at WHO clinical stage I at first treatment visit, patients at WHO clinical stage III [adjusted hazard ratio (aHR) 1.59, 95%CI: 1.21-2.09; p <0.001] or IV (aHR 2.41, 95%CI: 1.51-3.84; p <0.001) had increased risk of LTFU; whereas at registration, age category 35-44 (aHR 0.65, 95%CI: 0.44-0.98, p = 0.038) and 45 years and older (aHR 0.60, 95%CI: 0.39-0.93, p = 0.021) had a decreased risk. For death, patients assessed with WHO clinical stage II (aHR 2.35, 95%CI: 1.53-3.61, p<0.001), III (aHR 2.55, 95%CI: 1.75-3.71, p<0.001), and IV (aHR 4.21, 95%CI: 2.57-6.89, p<0.001) had an increased risk, while non-pregnant females (aHR 0.68, 95%CI: 0.51-0.92, p = 0.011) and pregnant females (aHR 0.42, 95%CI: 0.20-0.90, p = 0.026) had a decreased risk when compared to males. Suboptimal adherence was strongly associated with the experience of drug side effects-average adherence [adjusted odds ratio (aOR) 1.45, 95% CI: 1.06-1.99, p = 0.02) and poor adherence (aOR 1.75, 95%CI: 1.11-2.76, p = 0.016), and attending rural facility decreased the odds of average adherence (aOR 0.01, 95%CI: 0.01-0.03, p<0.001) and poor adherence (aOR 0.001, 95%CI: 0.0004-0.003, p<0.001). Loss-to-follow-up and poor adherence remain major challenges to achieving viral suppression targets in Liberia. Over two-fifths of patients engaged with the national HIV program are being lost to follow-up within 2 years of beginning care and treatment. WHO clinical stage III and IV were associated with LTFU while WHO clinical stage II, III and IV were associated with death. Suboptimal adherence was further associated with experience of drug side effects. Active support and close monitoring of patients who have signs of clinical progression and/or drug side effects could improve patient outcomes.
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Affiliation(s)
- Keith L Gray
- Health Services, Ministry of Health, Monrovia, Liberia
| | | | - Janjay Jones
- Health Services, Ministry of Health, Monrovia, Liberia
| | | | - Jethro S W Zawolo
- College of Health Sciences, University of Liberia, Monrovia, Liberia
| | | | - Naomi F Walker
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Julia T Garbo
- Health Services, Ministry of Health, Monrovia, Liberia
| | | | | | - Nahid Bhadelia
- Boston University, Massachusetts, United States of America
| | - Jean DeMarco
- University of North Carolina, Chapel Hill, North Carolina, United States of America
| | - Laura A Skrip
- College of Health Sciences, University of Liberia, Monrovia, Liberia
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Limbada M, Macleod D, Situmbeko V, Muhau E, Shibwela O, Chiti B, Floyd S, Schaap AJ, Hayes R, Fidler S, Ayles H. Rates of viral suppression in a cohort of people with stable HIV from two community models of ART delivery versus facility-based HIV care in Lusaka, Zambia: a cluster-randomised, non-inferiority trial nested in the HPTN 071 (PopART) trial. Lancet HIV 2022; 9:e13-e23. [PMID: 34843674 PMCID: PMC8716341 DOI: 10.1016/s2352-3018(21)00242-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Revised: 08/20/2021] [Accepted: 08/26/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Non-facility-based antiretroviral therapy (ART) delivery for people with stable HIV might increase sustainable ART coverage in low-income and middle-income countries. Within the HPTN 071 (PopART) trial, two interventions, home-based delivery (HBD) and adherence clubs (AC), which included groups of 15-30 participants who met at a communal venue, were compared with standard of care (SoC). In this trial we looked at the effectiveness and feasibility of these alternative models of care. Specifically, this trial aimed to assess whether these models of care had similar virological suppression to that of SoC 12 months after enrolment. METHODS This was a three-arm, cluster-randomised, non-inferiority trial, done in two urban communities in Lusaka, Zambia included in the HPTN 071 trial. The two communities were split into zones, which were randomly assigned (1:1:1) to the three treatment strategies: 35 zones to the SoC group, 35 zones to the HBD group, and 34 zones to the AC group. ART and adherence support were delivered once every 3 months at home for the HBD group, in groups of 15-30 people in the AC group, or in the clinic for the SoC group. Adults with HIV who were receiving first-line ART for at least 6 months, virally suppressed using national HIV guidelines in the last 12 months, had no other health conditions requiring the clinicians attention, live in the study catchment area, and provided written informed consent, were eligible for inclusion. The primary endpoint was viral suppression at 12 months (with a 6 month final measurement window [ie, 9-15 months]), defined as less than 1000 HIV RNA copies per mL, with a non-inferiority margin of 5%. FINDINGS Between May 5 and Dec 19, 2017, 9900 individuals were screened for inclusion, of whom 2489 (25·1%) participants were enrolled into the trial: 781 (31%) in the SoC group, 852 (34%) in the HBD group, and 856 (34%) in the AC group. A higher proportion of participants had viral load measurements in the primary outcome window in the HBD (581 [61%]of 852 participants) and AC (485 [57%] of 856 participants) groups than in the SoC (390 [50%] of 781 patients) group (p=0·0021). Of the 1096 missing observations, 152 (13·8%) were attributable to either deaths (25 [16%] participants), relocations (37 [24%] participants), or lost to follow-up (90 [59%]); 690 (63·0%) participants had viral load results outside the window period; and 254 (23·2%) did not have a viral load result. The prevalence of viral suppression was estimated to be 98·3% (95% CI 96·6 to 99·7) in the SoC group, 98·7% (97·5 to 99·6) in the HBD group, and 99·2% (98·4 to 99·8) in the AC group. This gave an estimated risk difference of 0·3% (95% CI -1·5 to 2·4) for the HBD group compared with the SoC group and 0·9% (-0·8 to 2·8) for the AC group compared with the SoC group. There was strong evidence (p<0·0001) that both community ART models were non-inferior to the SoC group (p<0·0001). INTERPRETATION Community models of ART delivery were as effective as facility-based care in terms of viral suppression. FUNDING National Institute of Allergy and Infectious Diseases, The International Initiative for Impact Evaluation (3ie), the Bill & Melinda Gates Foundation, National Institute on Drug Abuse, National Institute of Mental Health, and President's Emergency Plan for AIDS Relief.
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Affiliation(s)
| | - David Macleod
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | | | | | | | | | | | - Albertus J Schaap
- Zambart, Lusaka, Zambia; Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Richard Hayes
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Sarah Fidler
- Imperial College and Imperial college National Institute for Health Research Biomedical Research Centre, London, UK
| | - Helen Ayles
- Zambart, Lusaka, Zambia; Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK
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Cassidy T, Cornell M, Runeyi P, Dutyulwa T, Kilani C, Duran LT, Zokufa N, de Azevedo V, Boulle A, Horsburgh CR, Fox MP. Attrition from HIV care among youth initiating ART in youth-only clinics compared with general primary healthcare clinics in Khayelitsha, South Africa: a matched propensity score analysis. J Int AIDS Soc 2022; 25:e25854. [PMID: 35077610 PMCID: PMC8789247 DOI: 10.1002/jia2.25854] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 11/25/2021] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Youth living with HIV (YLWH) are less likely to initiate antiretroviral therapy (ART) and remain in care than older adults. It is important to identify effective strategies to address the needs of this growing population and prevent attrition from HIV care. Since 2008, two clinics have offered youth-targeted services exclusively to youth aged 12-25 in Khayelitsha, a high HIV-prevalence, low-income area in South Africa. We compared ART attrition among youth in these two clinics to youth in regular clinics in the same area. METHODS We conducted a propensity score matched cohort study of individuals aged 12-25 years initiating ART at eight primary care clinics in Khayelitsha between 1 January 2008 and 1 April 2018. We compared attrition, defined as death or loss to follow-up, between those attending two youth clinics and those attending general primary healthcare clinics, using Cox proportional hazards regression. Follow-up time began at ART initiation and ended at attrition, clinic transfer or dataset closure. We conducted sub-analyses of patients attending adherence clubs. RESULTS The distribution of age, sex and CD4 count at ART initiation was similar across Youth Clinic A (N = 1383), Youth Clinic B (N = 1299) and general clinics (N = 3056). Youth at youth clinics were more likely than those at general clinics to have initiated ART before August 2011 (Youth Clinic A: 16%, Youth Clinic B: 23% and general clinics: 11%). Youth clinics were protective against attrition: HR 0.81 (95% CI: 0.71-0.92) for Youth Clinic A and 0.85 (0.74-0.98) for Youth Clinic B, compared to general clinics. Youth Clinic A club patients had lower attrition after joining an adherence club than general clinic patients in adherence clubs (crude HR: 0.56, 95% CI: 0.32-0.96; adjusted HR: 0.48, 95% CI: 0.28-0.85), while Youth Clinic B showed no effect (crude HR: 0.83, 95% CI: 0.48-1.45; adjusted HR: 1.07, 95% CI: 0.60-1.90). CONCLUSIONS YLWH were more likely to be retained in ART care in two different youth-targeted clinics compared to general clinics in the same area. Our findings suggest that multiple approaches to making clinics more youth-friendly can contribute to improving retention in this important group.
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Affiliation(s)
- Tali Cassidy
- Médecins Sans Frontières, Cape Town, South Africa
- Division of Public Health Medicine, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Morna Cornell
- Centre for Infectious Disease Epidemiology & Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | | | | | | | | | | | | | - Andrew Boulle
- Centre for Infectious Disease Epidemiology & Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
- Western Cape Provincial Department of Health, Western Cape, South Africa
| | - C Robert Horsburgh
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, USA
- Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Matthew P Fox
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, USA
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, Department of Internal Medicine, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
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Chandiwana NC, Serenata CM, Owen A, Rannard S, Pérez Casas C, Scott C, Hill A, Clayden P, Flexner C. Impact of long-acting therapies on the global HIV epidemic. AIDS 2021; 35:S137-S143. [PMID: 34848580 DOI: 10.1097/qad.0000000000003102] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Long-acting antiretroviral drugs have emerged as exciting treatment and preexposure prophylaxis (PrEP) options for people with HIV and at risk of HIV. Long-acting regimens may improve dosing convenience, tolerability and cost compared with current daily-based oral therapy. They can also circumvent stigma associated with oral therapy for both treatment and PrEP, thereby improving adherence and outcomes. Yet, multiple challenges remain, many specific to low-income and middle-income countries (LMICs), where the epidemic is most concentrated and HIV prevention and treatment options are limited. To optimize the use of long-acting formulations, key outstanding questions must be addressed. Uncertain costing, scale-up manufacturing, complex delivery systems and implementation challenges are potential barriers when considering the scalability of long-acting ARVs for global use.
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Affiliation(s)
- Nomathemba C Chandiwana
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Celicia M Serenata
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Andrew Owen
- Department of Molecular and Clinical Pharmacology
| | - Steve Rannard
- Department of Chemistry, Centre of Excellence in Long-acting Therapeutics (CELT), University of Liverpool, Liverpool, United Kingdom
| | | | | | - Andrew Hill
- Department of Translational Medicine, Liverpool University, Liverpool
| | | | - Charles Flexner
- Divisions of Clinical Pharmacology and Infectious Diseases, School of Medicine and Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
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Ayala G, Sprague L, van der Merwe LLA, Thomas RM, Chang J, Arreola S, Davis SLM, Taslim A, Mienies K, Nilo A, Mworeko L, Hikuam F, de Leon Moreno CG, Izazola-Licea JA. Peer- and community-led responses to HIV: A scoping review. PLoS One 2021; 16:e0260555. [PMID: 34852001 PMCID: PMC8635382 DOI: 10.1371/journal.pone.0260555] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 10/18/2021] [Indexed: 01/18/2023] Open
Abstract
INTRODUCTION In June 2021, United Nations (UN) Member States committed to ambitious targets for scaling up community-led responses by 2025 toward meeting the goals of ending the AIDS epidemic by 2030. These targets build on UN Member States 2016 commitments to ensure that 30% of HIV testing and treatment programmes are community-led by 2030. At its current pace, the world is not likely to meet these nor other global HIV targets, as evidenced by current epidemiologic trends. The COVID-19 pandemic threatens to further slow momentum made to date. The purpose of this paper is to review available evidence on the comparative advantages of community-led HIV responses that can better inform policy making towards getting the world back on track. METHODS We conducted a scoping review to gather available evidence on peer- and community-led HIV responses. Using UNAIDS' definition of 'community-led' and following PRISMA guidelines, we searched peer-reviewed literature published from January 1982 through September 2020. We limited our search to articles reporting findings from randomized controlled trials as well as from quasi-experimental, prospective, pre/post-test evaluation, and cross-sectional study designs. The overall goals of this scoping review were to gather available evidence on community-led responses and their impact on HIV outcomes, and to identify key concepts that can be used to quickly inform policy, practice, and research. FINDINGS Our initial search yielded 279 records. After screening for relevance and conducting cross-validation, 48 articles were selected. Most studies took place in the global south (n = 27) and a third (n = 17) involved youth. Sixty-five percent of articles (n = 31) described the comparative advantage of peer- and community-led direct services, e.g., prevention and education (n = 23) testing, care, and treatment programs (n = 8). We identified more than 40 beneficial outcomes linked to a range of peer- and community-led HIV activities. They include improved HIV-related knowledge, attitudes, intentions, self-efficacy, risk behaviours, risk appraisals, health literacy, adherence, and viral suppression. Ten studies reported improvements in HIV service access, quality, linkage, utilization, and retention resulting from peer- or community-led programs or initiatives. Three studies reported structural level changes, including positive influences on clinic wait times, treatment stockouts, service coverage, and exclusionary practices. CONCLUSIONS AND RECOMMENDATIONS Findings from our scoping review underscore the comparative advantage of peer- and community-led HIV responses. Specifically, the evidence from the published literature leads us to recommend, where possible, that prevention programs, especially those intended for people living with and disproportionately affected by HIV, be peer- and community-led. In addition, treatment services should strive to integrate specific peer- and community-led components informed by differentiated care models. Future research is needed and should focus on generating additional quantitative evidence on cost effectiveness and on the synergistic effects of bundling two or more peer- and community-led interventions.
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Affiliation(s)
- George Ayala
- MPact Global Action for Gay Men’s Health and Rights, Oakland, CA, United States of America
- Alameda County Department of Public Health, Oakland, CA, United States of America
- * E-mail:
| | - Laurel Sprague
- Joint United Nations Programme on HIV/AIDS (UNAIDS), Geneva, Switzerland
| | - L. Leigh-Ann van der Merwe
- Social, Health and Empowerment Feminist Collective of Transgender Women in Africa, East London, South Africa
- Innovative Response Globally to Transgender Women and HIV (IRGT), Oakland, CA, United States of America
| | | | - Judy Chang
- International Network of People Who Use Drugs, London, United Kingdom
| | - Sonya Arreola
- MPact Global Action for Gay Men’s Health and Rights, Oakland, CA, United States of America
- Arreola Research, San Francisco, CA, United States of America
| | | | | | - Keith Mienies
- The Global Fund to Fight AIDS, Tuberculosis, and Malaria, Geneva, Switzerland
| | | | - Lillian Mworeko
- International Community of Women Living with HIV Eastern Africa, Kampala, Uganda
| | - Felicita Hikuam
- AIDS and Rights Alliance for Southern Africa, Windhoek, Namibia
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Brkic A, Kim JG, Haugeberg G, Diamantopoulos AP. Decentralizing healthcare in Norway to improve patient-centered outpatient clinic management of rheumatoid arthritis - a conceptual model. BMC Rheumatol 2021; 5:43. [PMID: 34743757 PMCID: PMC8572582 DOI: 10.1186/s41927-021-00215-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 07/07/2021] [Indexed: 12/14/2022] Open
Abstract
A growing population of older adults and improved effective treatments for inflammatory rheumatic diseases will increase the demand for more healthcare resources that already struggle with staggering outpatient clinic waiting times. Transformative delivery care models that provide sustainable healthcare services are urgently needed to meet these challenges. In this mini-review article, a proposed Lifelong Treatment Model for a decentralized follow-up of outpatient clinic patients living with rheumatoid arthritis is presented and discussed.Our conceptual model follows four steps for a transformative care delivery model supported by an Integrated Practice Unit; (1) Diagnosis, (2) Treatment, (3) Patient Empowered Disease Management, and (4) Telehealth. Through an Integrated Practice Unit, a multidisciplinary team could collaborate with patients with rheumatoid arthritis to facilitate high-value care that addresses most important outcomes of the patients; (1) Early Remission, (2) Decentralization, (3) Improved Quality of Life, and (4) Lifelong Sustain Remission.The article also addresses the growing challenges for the healthcare delivery system today for patients with rheumatoid arthritis and proposes how to reduce outpatient clinic visits without compromising quality and safety.
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Affiliation(s)
- Alen Brkic
- Department of Research, Sorlandet Hospital, Service Box 416, Kristiansand, Norway.
| | - Jung G Kim
- Kaiser Permanente Bernard J. Tyson School of Medicine, Department of Health Systems Science, Pasadena, CA, USA
| | - Glenn Haugeberg
- Division of Rheumatology, Department of medicine, Sorlandet Hospital, Kristiansand, Norway
| | - Andreas P Diamantopoulos
- Department of Rheumatology, Martina Hansens Hospital, Bærum (Oslo), Norway.,Division of Rheumatology, Department of Medicine, Akershus University Hospital, Kongsvinger, Norway
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Tsui S, Kennedy CE, Moulton LH, Chang LW, Farley JE, Torpey K, van Praag E, Koole O, Ford N, Wabwire-Mangen F, Denison JA. HIV care and treatment models and their association with medication possession ratio among treatment-experienced adults in three African countries. Trop Med Int Health 2021; 26:1481-1493. [PMID: 34265155 PMCID: PMC8563398 DOI: 10.1111/tmi.13654] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE How clinics structure the delivery of antiretroviral therapy (ART) services may influence patient adherence. We assessed the relationship between models of HIV care delivery and adherence as measured by medication possession ratio (MPR) among treatment-experienced adults in Tanzania, Uganda and Zambia. METHODS Eighteen clinics were grouped into three models of HIV care. Model 1-Traditional and Model 2-Mixed represented task-sharing of clinical services between physicians and clinical officers, distinguished by whether nurses played a role in clinical care; in Model 3-Task-Shifted, clinical officers and nurses shared clinical responsibilities without physicians. We assessed MPR among 3,419 patients and calculated clinic-level MPR summaries. We then calculated the mean differences of percentages and adjusted residual ratio (aRR) of the association between models of care and incomplete adherence, defined as a MPR <90%, adjusting for individual-level characteristics. RESULTS In the adjusted analysis, patients in Model 1-Traditional were more likely than patients in Model 2-Mixed to have MPR <90% (aRR = 1.60, 95% CI 1-2.48). Patients in Model 1-Traditional were no more likely than patients in Model 3-Task-Shifted to have a MPR <90% (aRR = 1.58, 95% 0.88-2.85). There was no evidence of differences in MPR <90% between Model 2-Mixed and Model 3-Task-Shifted (aRR = 0.99, 95% CI 0.59-1.66). CONCLUSION Non-physician-led ART programmes were associated with adherence levels as good as or better than physician-led ART programmes. Additional research is needed to optimise models of care to support patients on lifelong treatment.
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Affiliation(s)
- Sharon Tsui
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Caitlin E. Kennedy
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Lawrence H. Moulton
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Larry W. Chang
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
- Department of Medicine – Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Jason E. Farley
- Department of Medicine – Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, USA
- The REACH Initiative of The Johns Hopkins School of Nursing, Baltimore, USA
- University of KwaZulu Natal, Durban, South Africa
- Association of Nurses in AIDS Care, Akron, USA
| | - Kwasi Torpey
- School of Public Health, University of Ghana College of Health Sciences, Accra, Ghana
| | | | - Olivier Koole
- Clinical Sciences Department, Institute of Tropical Medicine, Antwerp, Belgium
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, UK
| | - Nathan Ford
- Dept HIV, World Health Organization, Geneva, Switzerland
| | - Fred Wabwire-Mangen
- Department of Epidemiology and Biostatistics, Makerere University School of Public Health, Kampala, Uganda
| | - Julie A. Denison
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
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Gausi B, Berkowitz N, Jacob N, Oni T. Treatment outcomes among adults with HIV/non-communicable disease multimorbidity attending integrated care clubs in Cape Town, South Africa. AIDS Res Ther 2021; 18:72. [PMID: 34649586 PMCID: PMC8515722 DOI: 10.1186/s12981-021-00387-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Accepted: 09/15/2021] [Indexed: 12/01/2022] Open
Abstract
Background The growing burden of the HIV and non-communicable disease (NCD) syndemic in Sub- Saharan Africa has necessitated introduction of integrated models of care in order to leverage existing HIV care infrastructure for NCDs. However, there is paucity of literature on treatment outcomes for multimorbid patients attending integrated care. We describe 12-month treatment outcomes among multimorbid patients attending integrated antiretroviral treatment (ART) and NCD clubs in Cape Town, South Africa. Methods As part of an integrated clubs (IC) model pilot implemented in 2016 by the local government at two primary health care clinics in Cape Town, we identified all multimorbid patients who were enrolled for IC for at least 12 months by August 2017. Mean adherence percentages (using proxy of medication collection and attendance of club visits) and optimal disease control (defined as the proportion of participants achieving optimal blood pressure, glycosylated haemoglobin control and HIV viral load suppression where appropriate) were calculated at 12 months before, at the point of IC enrolment and 12 months after IC enrolment. Predictors of NCD control 12 months post IC enrolment were investigated using multivariable logistic regression. Results As of 31 August 2017, 247 HIV-infected patients in total had been enrolled into IC for at least 12 months. Of these, 221 (89.5%) had hypertension, 4 (1.6%) had diabetes mellitus and 22 (8.9%) had both diseases. Adherence was maintained before and after IC enrolment with mean adherence percentages of 92.2% and 94.2% respectively. HIV viral suppression rates were 98.6%, 99.5% and 99.4% at the three time points respectively. Retention in care was high with 6.9% lost to follow up at 12 months post IC enrolment. Across the 3 time-points, optimal blood pressure control was achieved in 43.1%, 58.9% and 49.4% of participants while optimal glycaemic control was achieved in 47.4%, 87.5% and 53.3% of participants with diabetes respectively. Multivariable logistic analyses showed no independent variables significantly associated with NCD control. Conclusion Multimorbid adults living with HIV achieved high levels of HIV control in integrated HIV and NCD clubs. However, intensified interventions are needed to maintain NCD control in the long term. Supplementary Information The online version contains supplementary material available at 10.1186/s12981-021-00387-3.
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Gilbert HN, Wyatt MA, Pisarski EE, Asiimwe S, van Rooyen H, Seeley J, Shahmanesh M, Turyamureeba B, van Heerden A, Adeagbo O, Celum CL, Barnabas RV, Ware NC. How community ART delivery may improve HIV treatment outcomes: Qualitative inquiry into mechanisms of effect in a randomized trial of community-based ART initiation, monitoring and re-supply (DO ART) in South Africa and Uganda. J Int AIDS Soc 2021; 24:e25821. [PMID: 34624173 PMCID: PMC8500674 DOI: 10.1002/jia2.25821] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 08/03/2021] [Indexed: 02/05/2023] Open
Abstract
Introduction UNAIDS fast track targets for ending the AIDS epidemic by 2030 call for viral suppression in 95% of people using antiretroviral therapy (ART) to treat HIV infection. Difficulties in linking to care following a positive HIV test have impeded progress towards meeting treatment targets. Community‐based HIV services may reduce linkage barriers and have been associated with high retention and favourable clinical outcomes. We use qualitative data from The Delivery Optimization of Antiretroviral Therapy (DO ART) Study, a three‐arm randomized trial of community ART initiation, monitoring and re‐supply conducted in western Uganda and KwaZulu‐Natal South Africa, to identify mechanisms through which community ART delivery may improve treatment outcomes, defined as viral suppression in people living with HIV (PLHIV). Methods We conducted open‐ended interviews with a purposeful sample of 150 DO ART participants across study arms and study sites, from October 2016 to November 2019. Interviews covered experiences of: (1) HIV testing; (2) initiating and refilling ART; and (3) participating in the DO ART Study. A combined inductive content analytic and thematic approach was used to characterize mechanisms through which community delivery of ART may have contributed to viral suppression in the DO ART trial. Results The analysis yielded four potential mechanisms drawn from qualitative data representing the perspectives and priorities of DO ART participants. Empowering participants to schedule, re‐schedule and select the locations of community‐based visits via easy phone contact with clinical staff is characterized as flexibility. Integration refers to combining the components of clinic‐based visits into single interaction with a healthcare provider. Providers” willingness to talk at length with participants during visits, addressing non‐HIV as well as HIV‐related concerns, is termed “a slower pace”. Finally, increased efficiency denotes the time savings and increased income‐generating opportunities for participants brought about by delivering services in the community. Conclusions Understanding the mechanisms through which HIV service delivery innovations produce an effect is key to transferability and potential scale‐up. The perspectives and priorities of PLHIV can indicate actionable changes for HIV care programs that may increase engagement in care and improve treatment outcomes.
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Affiliation(s)
- Hannah N Gilbert
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Monique A Wyatt
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA.,Harvard Global, Cambridge, Massachusetts, USA
| | - Emily E Pisarski
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Stephen Asiimwe
- Mbarara University of Science and Technology, Mbarara, Uganda.,Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts, USA.,Integrated Community-based Initiatives, Kabwohe, Uganda
| | - Heidi van Rooyen
- Human Sciences Research Council, KwaZulu-Natal, South Africa.,SAMRC/Wits Developmental Pathways for Health Research Unit, Department of Paediatrics, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Janet Seeley
- London School of Hygiene and Tropical Medicine, London, UK.,Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - Maryam Shahmanesh
- Africa Health Research Institute, KwaZulu-Natal, South Africa.,Institute for Global Health, University College London, London, UK
| | | | - Alastair van Heerden
- Human Sciences Research Council, KwaZulu-Natal, South Africa.,SAMRC/Wits Developmental Pathways for Health Research Unit, Department of Paediatrics, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Connie L Celum
- Departments of Global Health and Medicine, University of Washington, Seattle, Washington, USA
| | - Ruanne V Barnabas
- Departments of Global Health and Medicine, University of Washington, Seattle, Washington, USA
| | - Norma C Ware
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA.,Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
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- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
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Masa R, Baca-Atlas S, Hangoma P. Walking and perceived lack of safety: Correlates and association with health outcomes for people living with HIV in rural Zambia. JOURNAL OF TRANSPORT & HEALTH 2021; 22:101140. [PMID: 35495575 PMCID: PMC9053861 DOI: 10.1016/j.jth.2021.101140] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
INTRODUCTION Geographic inaccessibility disproportionately affects health outcomes of rural populations due to lack of suitable transport, prolonged travel time, and poverty. Rural patients are left with few transport options to travel to a health facility. One common option is to travel by foot, which may present additional challenges, such as perceived lack of safety while transiting. We examined the correlates of perceived lack of safety when walking to a health facility and its association with treatment and psychosocial outcomes among adults living with HIV. METHODS Data were collected from 101 adults living with HIV in Eastern Province, Zambia. All participants were receiving antiretroviral therapy at one of two health clinics. Perceived lack of safety was measured by asking respondents whether they felt unsafe traveling to and from the health facility in which they were receiving their HIV care. Outcomes included medication adherence, perceived stress, hope for the future, and barriers to pill taking. Linear and logistic regression methods were used to examine the correlates of perceived safety and its association with health outcomes. RESULTS Being older, a woman, having a primary education, living farther from a health facility, traveling longer to reach a health facility, and owing money were associated with higher likelihood of feeling unsafe when traveling by foot to health facility. Perceived lack of safety was associated with medication nonadherence, higher level of stress, lower level of agency, and more barriers to pill taking. CONCLUSIONS Perceived lack of safety when traveling by foot to a health facility may be a barrier to better treatment and psychosocial outcomes, especially among rural patients. Practitioners and policymakers should consider implementation of differentiated HIV service delivery models to reduce frequent travel to health facilities and to alleviate ART patients' worry about lack of safety when traveling by foot to a health facility.
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Affiliation(s)
- Rainier Masa
- School of Social Work, University of North Carolina at Chapel Hill, USA
- Global Social Development Innovations, University of North Carolina at Chapel Hill, USA
| | | | - Peter Hangoma
- School of Public Health, University of Zambia, Lusaka, Zambia
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Mash R, Christian C, Chigwanda RV. Alternative mechanisms for delivery of medication in South Africa: A scoping review. S Afr Fam Pract (2004) 2021; 63:e1-e8. [PMID: 34476963 PMCID: PMC8424755 DOI: 10.4102/safp.v63i1.5274] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 05/19/2021] [Accepted: 06/22/2021] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND The number of people in South Africa with chronic conditions is a challenge to the health system. In response to the coronavirus infection, health services in Cape Town introduced home delivery of medication by community health workers. In planning for the future, they requested a scoping review of alternative mechanisms for delivery of medication to patients in primary health care in South Africa. METHODS Databases were systematically searched using a comprehensive search strategy to identify studies from the last 10 years. A methodological guideline for conducting scoping reviews was followed. A standardised template was used to extract data and compare study characteristics and findings. Data was analysed both quantitatively and qualitatively. RESULTS A total of 4253 publications were identified and 26 included. Most publications were from the last 5 years (n = 21), research (n = 24), Western Cape (n = 15) and focused on adherence clubs (n = 17), alternative pick-up-points (n = 14), home delivery (n = 5) and HIV (n = 17). The majority of alternative mechanisms were supported by a centralised dispensing and packaging system. New technology such as smart lockers and automated pharmacy dispensing units have been piloted. Patients benefited from these alternatives and had improved adherence. Available evidence suggests alternative mechanisms were cheaper and more beneficial than attending the facility to collect medication. CONCLUSION A mix of options tailored to the local context and patient choice that can be adequately managed by the system would be ideal. More economic evaluations are required of the alternatives, particularly before going to scale and for newer technology.
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Affiliation(s)
- Robert Mash
- Division of Family Medicine and Primary Care, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town.
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Steward WT, Agnew E, de Kadt J, Ratlhagana MJ, Sumitani J, Gilmore HJ, Grignon J, Shade SB, Tumbo J, Barnhart S, Lippman SA. Impact of SMS and peer navigation on retention in HIV care among adults in South Africa: results of a three-arm cluster randomized controlled trial. J Int AIDS Soc 2021; 24:e25774. [PMID: 34435440 PMCID: PMC8387209 DOI: 10.1002/jia2.25774] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 06/10/2021] [Accepted: 07/08/2021] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION Few interventions have demonstrated improved retention in care for people living with HIV (PLHIV) in sub-Saharan Africa. We tested the efficacy of two personal support interventions - one using text messaging (SMS-only) and the second pairing SMS with peer navigation (SMS+PN) - to improve HIV care retention over one year. METHODS In a cluster randomized control trial (NCT# 02417233) in North West Province, South Africa, we randomized 17 government clinics to three conditions: SMS-only (6), SMS+PN (7) or standard of care (SOC; 4). Participants at SMS-only clinics received appointment reminders, biweekly healthy living messages and twice monthly SMS check-ins. Participants at SMS+PN clinics received SMS appointment reminders and healthy living messages and spoke at least twice monthly with peer navigators (PLHIV receiving care) to address barriers to care. Outcomes were collected through biweekly clinical record extraction and surveys at baseline, six and 12 months. Retention in HIV care over one year was defined as clinic visits every three months for participants on antiretroviral therapy (ART) and CD4 screening every six months for pre-ART participants. We used generalized estimating equations, adjusting for clustering by clinic, to test for differences across conditions. RESULTS Between October 2014 and April 2015, we enrolled 752 adult clients recently diagnosed with HIV (SOC: 167; SMS-only: 289; SMS+PN: 296). Individuals in the SMS+PN arm had approximately two more clinic visits over a year than those in other arms (p < 0.01) and were more likely to be retained in care over one year than those in SOC clinics (54% vs. 38%; OR: 1.77, CI: 1.02, 3.10). Differences between SMS+PN and SOC conditions remained significant when restricting analyses to the 628 participants on ART (61% vs. 45% retained; OR: 1.78, CI: 1.08, 2.93). The SMS-only intervention did not improve retention relative to SOC (40% vs. 38%, OR: 1.12, CI: 0.63, 1.98). CONCLUSIONS A combination of SMS appointment reminders with personalized, peer-delivered support proved effective at enhancing retention in HIV care over one year. While some clients may only require appointment reminders, the SMS+PN approach offers increased flexibility and tailored, one-on-one support for patients struggling with more substantive challenges.
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Affiliation(s)
- Wayne T Steward
- Division of Prevention ScienceDepartment of MedicineUniversity of CaliforniaSan FranciscoCAUSA
| | - Emily Agnew
- Division of Prevention ScienceDepartment of MedicineUniversity of CaliforniaSan FranciscoCAUSA
| | - Julia de Kadt
- International Training and Education Center for Health (I‐TECH)PretoriaRepublic of South Africa
| | - Mary Jane Ratlhagana
- International Training and Education Center for Health (I‐TECH)PretoriaRepublic of South Africa
| | - Jeri Sumitani
- International Training and Education Center for Health (I‐TECH)PretoriaRepublic of South Africa
| | - Hailey J Gilmore
- Division of Prevention ScienceDepartment of MedicineUniversity of CaliforniaSan FranciscoCAUSA
| | - Jessica Grignon
- International Training and Education Center for Health (I‐TECH)PretoriaRepublic of South Africa
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
- International Training and Education Center for Health (I‐TECH) South AfricaPretoriaRepublic of South Africa
| | - Starley B Shade
- Division of Prevention ScienceDepartment of MedicineUniversity of CaliforniaSan FranciscoCAUSA
- Institute for Global Health SciencesDepartment of Epidemiology and BiostatisticsUniversity of CaliforniaSan FranciscoCAUSA
| | - John Tumbo
- Department of Family Medicine and Primary Health CareSefako Makgatho Health Sciences UniversityPretoriaRepublic of South Africa
| | - Scott Barnhart
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
- International Training and Education Center for Health (I‐TECH) South AfricaPretoriaRepublic of South Africa
| | - Sheri A Lippman
- Division of Prevention ScienceDepartment of MedicineUniversity of CaliforniaSan FranciscoCAUSA
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Okere NE, Lennox L, Urlings L, Ford N, Naniche D, Rinke de Wit TF, Hermans S, Gomez GB. Exploring Sustainability in the Era of Differentiated HIV Service Delivery in Sub-Saharan Africa: A Systematic Review. J Acquir Immune Defic Syndr 2021; 87:1055-1071. [PMID: 33770063 PMCID: PMC8219088 DOI: 10.1097/qai.0000000000002688] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 03/01/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION The World Health Organization recommends differentiated service delivery (DSD) to support resource-limited health systems in providing patient-centered HIV care. DSD offers alternative care models to clinic-based care for people living with HIV who are stable on antiretroviral therapy (ART). Despite good patient-related outcomes, there is limited evidence of their sustainability. Our review evaluated the reporting of sustainability indicators of DSD interventions conducted in sub-Saharan Africa (SSA). METHODS We searched PubMed and EMBASE for studies conducted between 2000 and 2019 assessing DSD interventions targeting HIV-positive individuals who are established in ART in sub-Saharan Africa. We evaluated them through a comprehensive sustainability framework of constructs categorized into 6 domains (intervention design, process, external environment, resources, organizational setting, and people involvement). We scored each construct 1, 2, or 3 for no, partial, or sufficient level of evidence, respectively. Interventions with a calculated sustainability score (overall and domain-specific) of >90% or domain-specific median score >2.7 were considered likely to be sustainable. RESULTS Overall scores ranged from 69% to 98%. Top scoring intervention types included adherence clubs (98%) and community ART groups (95%) which comprised more than half of interventions. The highest scoring domains were design (2.9) and organizational setting (2.8). The domains of resources (2.4) and people involvement (2.3) scored lowest revealing potential areas for improvement to support DSD sustainability. CONCLUSIONS With the right investment in stakeholder involvement and domestic funding, DSD models generally show potential for sustainability. Our results could guide informed decisions on which DSD intervention is likely to be sustainable per setting and highlight areas that could motivate further research.
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Affiliation(s)
- Nwanneka E. Okere
- Department of Global Health, Amsterdam Institute for Global Health and Development, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Laura Lennox
- Department of Primary Care and Public health, Imperial College, National Institute for Health Research, Applied Research Collaboration, North West London, London, United Kingdom
| | - Lisa Urlings
- Department of Medicine, Amsterdam UMC University of Amsterdam, Amsterdam, Netherlands
| | - Nathan Ford
- Department HIV, World Health Organization, Geneva, Switzerland
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Denise Naniche
- ISGlobal, Barcelona Institute for Global Health, Hospital Clinic-University of Barcelona, Barcelona, Spain
| | - Tobias F. Rinke de Wit
- Department of Global Health, Amsterdam Institute for Global Health and Development, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Sabine Hermans
- Department of Global Health, Amsterdam Institute for Global Health and Development, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Gabriela B. Gomez
- Department of Global Health and Development, London School of Health and Tropical Medicine, London, United Kingdom; and
- Department of Modelling, Epidemiology and Data Science, Currently, Sanofi Pasteur, Lyon,France
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