Scaling-up access to antiretroviral therapy for children: a cohort study evaluating care and treatment at mobile and hospital-affiliated HIV clinics in rural Zambia

Empowering Communities: A Review of Community-Based Outreach Programs in Controlling Hypertension in India

India's epidemiological shift from communicable to non-communicable diseases (NCDs) signifies the impact of healthcare advancements and changing lifestyles. Despite declines in infectious diseases, challenges related to chronic conditions such as cardiovascular diseases and diabetes have risen. Approximately one in four Indian adults has hypertension, with only 12% maintaining controlled blood pressure. To meet the 25% relative reduction target in hypertension prevalence by 2025, India must enhance treatment access and public health initiatives. A global report underscores the urgency of preventing, detecting, and managing hypertension, especially in low- and middle-income countries like India, where 188.3 million adults are estimated to have hypertension. Loss to follow-up persists in both communicable and non-communicable diseases, driven by factors such as stigma and socioeconomic barriers. Community outreach programs have proven effective, incorporating mobile health interventions, community health worker engagement, and door-to-door screenings. Hypertension management faces similar challenges, with community outreach tailored to lifestyle factors and cultural beliefs showing promise. The comprehensive strategy to control hypertension involves strengthening primary healthcare centers, promoting wellness centers, and capacitating Community Health Officers. While community-led, tech-enabled private sector interventions can screen and manage NCDs, integration with the public health system is crucial for widespread adoption and cost-effectiveness. In conclusion, tailored strategies, such as community outreach integrated into healthcare systems, are essential to address loss to follow-up and enhance health management success in both communicable and non-communicable diseases.

The Evolving Pediatric HIV Epidemic in Rural Southern Zambia: The Beneficial Impact of Advances in Prevention and Treatment at a District Hospital From 2007 to 2019

BACKGROUND

Remarkable progress has been made in expanding access to services addressing the pediatric HIV epidemic, including programs to prevent mother-to-child transmission, early diagnosis and treatment for children living with HIV. Few long-term data are available from rural sub-Saharan Africa to assess implementation and impact of national guidelines.

METHODS

Results from 3 cross-sectional studies and 1 cohort study conducted at Macha Hospital in Southern Province, Zambia from 2007 to 2019 were summarized. For infant diagnosis, maternal antiretroviral treatment, infant test results and turnaround times for results were evaluated by year. For pediatric HIV care, the number and age of children initiating care and treatment, and treatment outcomes within 12 months were evaluated by year.

RESULTS

Receipt of maternal combination antiretroviral treatment increased from 51.6% in 2010-2012 to 93.4% in 2019, and the proportion of infants testing positive decreased from 12.4% to 4.0%. Turnaround times for results returning to clinic varied but were shorter when labs consistently used a text messaging system. The proportion of mothers receiving results was higher when a text message intervention was piloted. The number of children living with HIV enrolled into care and the proportion initiating treatment with severe immunosuppression and dying within 12 months decreased over time.

CONCLUSIONS

These studies demonstrate the long-term beneficial impact of implementing a strong HIV prevention and treatment program. While expansion and decentralization brought challenges, the program succeeded in decreasing the rate of mother-to-child transmission and ensuring that children living with HIV benefit from access to life-saving treatment.

Primary Health Center: Can it be made mobile for efficient healthcare services for hard to reach population? A state-of-the-art review

Indian healthcare system is in immediate need of a new healthcare delivery model to increase healthcare accessibility and improve the health outcomes of the marginalized. Inaccessibility and underutilization of Primary Health Centers (PHCs) disproportionately affect people living in remote areas. It is thus imperative for the designers, engineers, health professionals, and policymakers to come together with a collaborative mindset to develop innovative interventions that sustainably manage the accessibility of PHCs at large, promote preventive health, and thus improve the health outcomes of hard-to-reach communities. This article examines the available literature on barriers to primary healthcare in Indian context, the reason of failure of PHCs and the way forward. The article further analysis literature on existing Mobile Medical Units (MMUs) as an alternate solution to conventional PHCs and attempt to extract the major lessons to propose a mobile Primary Health Center (mPHC) in contrast to the existing conventional static PHCs. The intention is to find out the research gaps in the existing literature and try to address the same for future researchers, designers, engineers, health professionals and policy makers to think forward to make this idea of a mobile Primary Health Center (mPHC), as the main delivery model to cater basic healthcare services to the underserved communities.

Making primary healthcare delivery robust for low resource settings: Learning from Mohalla Clinics

The present healthcare scenario is still in its compromised state, whether it is the lack of infrastructure, medicines and human resources, especially in rural India. Moreover, the condition worsens in rural areas due to several reasons like lack of awareness, proper roads to access, and lack of proper delivery of healthcare model. The state government of Delhi, India, set up the "Mohalla" Clinics to provide essential healthcare to residents of Delhi and the surrounding areas, focusing on the urban poor. Essential health services, such as vaccinations, family planning, and counselling, are available at the Mohalla Clinics, where a doctor, a nurse, a pharmacist, and a lab technician are staffed. Despite a strong start and low operating costs, the Mohalla Clinic initiative still struggles to cover all Delhi state as envisioned. This study analyses the operational challenges of Delhi's "Mohalla" Clinics and proposes lessons to be implemented for other primary healthcare infrastructure services for remote areas. The analysis is based on the systems (infrastructure, facilities, and services) strengths and limitations from a literature review and qualitative interview conducted among 55 respondents, including doctors, nurses, and patients among 11 Mohalla Clinics using the SUTD-MIT (Singapore University of Technology and Design-Massachusetts Institute of Technology Industrial Design Centre) interview template for Product Service System (PSS). The results show that there are lessons to learn from the model of Delhi Mohalla Clinics for other states to implement in their primary healthcare sectors. To achieve Universal Health Coverage (UHC), the Delhi Mohalla Clinic falls short due to several limitations. Thus, to achieve UHC, the Indian healthcare system needs a new healthcare delivery model. Hence, we ought to propose a new healthcare delivery model based on the gained insights from the study. One such delivery model proposed is a mobile Primary Health Center (mPHC). This collapsible system can be taken to far-flung regions, deployed for some hours, run the Out-Patient Department (OPD), collapsed, and returned to base.

Cognitive and academic performance of rural Zambian youth exposed to HIV

Studies focusing on children affected by HIV have shown that they have generally lower academic performance, however, few studies separate children who are HIV exposed and infected (CHEI) and those who are HIV exposed but uninfected (CHEU). Importantly, in rural sub-Saharan Africa, the majority of studies on CHEI and CHEU examine academic performance indirectly based on cognitive test scores. Therefore, studies assessing the effects of HIV on academic achievement directly for CHEI and CHEU are needed. This article evaluates the effects of HIV-infection on cognitive and academic performance by comparing CHEI (n = 82) and CHEU (n = 1045) aged 7-17 years old using cross-sectional data from an ongoing longitudinal study in a rural area of Zambia. Youth completed cognitive and academic assessments; their height and weight were assessed to generate Body Mass Index (BMI). Caregiver questionnaires provided information on youths' years in school and household socio-economic status (SES). Results indicated that while HIV infection status did explain some of the variance in performance between CHEI and CHEU, age, BMI, years of schooling and SES accounted for additional variance. The effect of years of schooling on both cognitive and academic performance demonstrated that CHEI's performance may be greatly improved by consistent school enrollment.

CD4 Trends With Evolving Treatment Initiation Policies Among Children Living With HIV in Zambézia Province, Mozambique, 2012-2018

BACKGROUND

Historically, antiretroviral therapy (ART) initiation was based on CD4 criteria, but this has been replaced with "Test and Start" wherein all people living with HIV are offered ART. We describe the baseline immunologic status among children relative to evolving ART policies in Mozambique.

METHODS

This retrospective evaluation was performed using routinely collected data. Children living with HIV (CL aged 5-14 years) with CD4 data in the period of 2012-2018 were included. ART initiation "policy periods" corresponded to implementation of evolving guidelines: in period 1 (2012-2016), ART was recommended for CD4 <350 cells/mm3; during period 2 (2016-2017), the CD4 threshold increased to <500 cells/mm3; Test and Start was implemented in period 3 (2017-2018). We described temporal trends in the proportion of children with severe immunodeficiency (CD4 <200 cells/mm3) at enrollment and at ART initiation. Multivariable regression models were used to estimate associations with severe immunodeficiency.

RESULTS

The cohort included 1815 children with CD4 data at enrollment and 1922 at ART initiation. The proportion of children with severe immunodeficiency decreased over time: 20% at enrollment into care in period 1 vs. 16% in period 3 (P = 0.113) and 21% at ART initiation in period 1 vs. 15% in period 3 (P = 0.004). Children initiating ART in period 3 had lower odds of severe immunodeficiency at ART initiation compared with those in period 1 [adjusted odds ratio (aOR) = 0.67; 95% CI: 0.51 to 0.88]. Older age was associated with severe immunodeficiency at enrollment (aOR = 1.13; 95% CI: 1.06 to 1.20) and at ART initiation (aOR = 1.14; 95% CI: 1.08 to 1.21).

CONCLUSIONS

The proportion of children with severe immunodeficiency at ART initiation decreased alongside more inclusive ART initiation guidelines. Earlier treatment of children living with HIV is imperative.

Cascade of care in people living with HIV in Iran in 2019; how far to reach UNAIDS/WHO targets

Systematic HIV program evaluation requires looking at all steps of the HIV cascade of care, from diagnosis to treatment outcomes. Our study was carried out to assess the treatment cascade of people living with HIV (PLWH) in Iran in 2019. We used data from the HIV Case Registry System of Iran through December 2019. We estimated the number of PLWH in 2019 by using Spectrum, and then the proportion of them being diagnosed, linked to care, received antiretroviral treatment and suppressed viral load. We estimated that there are 59,314 (UI: 32,685-125,636) PLWH in Iran, of whom 22,054 people (37% of PLWH) were diagnosed. At the end of 2019, of whom, 14,685 (25% of PLWH) people received antiretroviral therapy. Also, of whom 6338 (11% of PLWH) people had viral load suppression by 2019. Our results showed that about one-third of total PLWH were diagnosed, while this defect is somewhat less in children than adults. To reach the 90.90.90 targets Iran needs to developed the current national HIV care guidelines, which recommend best strategies to scale up the case finding and linkage to care among undiagnosed people specifically those who infected by sexual contact in general and key populations as well.

Attrition of HIV-exposed infants from early infant diagnosis services in low- and middle-income countries: a systematic review and meta-analysis

INTRODUCTION

Identification and retention of HIV-exposed infants in early infant diagnosis (EID) services helps to ensure optimal health outcomes. This systematic review and meta-analysis examines the magnitude of attrition from EID services in low- and middle-income countries (LMICs).

METHODS

We performed a comprehensive database search through April 2016. We included original studies reporting retention/attrition data for HIV-exposed infants in LMICs. Outcomes included loss to follow-up (LTFU), death and overall attrition (LTFU + death) at time points along the continuum of EID services. At least two authors determined study eligibility, performed data extraction and made quality assessments. We used random-effects meta-analytic methods to aggregate effect sizes and perform meta-regression analyses. This study adhered to PRISMA reporting guidelines.

RESULTS

We identified 3040 unique studies, of which 92 met eligibility criteria and were included in the quantitative synthesis. The included studies represent data from 110,805 HIV-exposed infants, the majority of whom were from Africa (77%). LTFU definitions varied widely, and there was significant variability in outcomes across studies. The bulk of attrition occurred in the first six months of follow-up, with additional losses over time. Overall, 39% of HIV-exposed infants were no longer in care at 18 months. When restricted to non-intervention studies, 43% were not retained at 18 months.

CONCLUSIONS

These findings underscore the high attrition of HIV-exposed infants from EID services in LMICs and the urgent need for implementation research and resources to improve retention among this vulnerable population.

The impact of a private-public partnership delivery system on the HIV continuum of care in a South Indian city

We characterized the impact of a Private-Public Partnership (PPP) on the continuum of HIV care (e.g., treatment initiation, ART effectiveness and loss to follow-up) among adults enrolled at a private hospital/ART link center in the southern state of Karnataka, India from 2007 through 2012. Data on 2326 adults in care were compiled using an electronic database supplemented with medical chart abstraction. Survival methods with staggered entries were used to analyze time to ART initiation and loss to follow-up as well as associated factors. Mixed effects linear regression models were used to assess ART effectiveness. The mean age of adults in care was 36 years; 40% were male. The majority were married, had less than primary education, and less than 45 US dollars (3000 Indian Rupee) monthly income. The mean CD4 at presentation was 527 cells/mm³. The median time from ART eligibility to initiation was 5 and 2 months for before and after the PPP, respectively (p < 0.001). Becoming eligible after PPP was associated with more rapid treatment initiation (Hazard Ratio: [95% Confidence Interval] 1.49 [1.11, 1.99]). Moreover, among the 1639 persons lost to follow-up, more rapid loss was observed before the PPP (12.77 months) vs. after (13.37 months) (p = 0.25) and there was a significant interaction between ART status and calendar time before and after the PPP (p < 0.001). Being on treatment was associated with a lower likelihood of becoming lost before the PPP (HR: [95% CI] 0.33 [0.27, 0.42]), but this association was reversed after the PPP (HR: [95% CI] 1.77 [1.54, 2.04]), p-value for interaction <0.001. Treatment response measured by CD4 was comparable before and after the PPP (p = 0.088). Our findings suggest that PPP models of ART delivery may improve HIV treatment initiation and loss to follow-up without compromising the effectiveness of treatment. Efforts to expand these system-level interventions should be considered with on-going evaluation.

Clinical outcomes in children and adolescents initiating antiretroviral therapy in decentralized healthcare settings in Zimbabwe

INTRODUCTION

Decentralized HIV care for adults does not appear to compromise clinical outcomes. HIV care for children poses additional clinical and social complexities. We conducted a prospective cohort study to investigate clinical outcomes in children aged 6-15 years who registered for HIV care at seven primary healthcare clinics (PHCs) in Harare, Zimbabwe.

METHODS

Participants were recruited between January 2013 and December 2014 and followed for 18 months. Rates of and reasons for mortality, hospitalization and unscheduled PHC attendances were ascertained. Cox proportional modelling was used to determine the hazard of death, unscheduled attendances and hospitalization.

RESULTS

We recruited 385 participants, median age 11 years (IQR: 9-13) and 52% were female. The median CD4 count was 375 cells/mm3 (IQR: 215-599) and 77% commenced ART over the study period, with 64% of those who had viral load measured achieving an HIV viral load <400 copies/ml. At 18 months, 4% of those who started ART vs. 24% of those who remained ART-naïve were lost-to-follow-up (p < 0.001). Hospitalization and mortality rates were low (8.14/100 person-years (pyrs) and 2.86/100 pyrs, respectively). There was a high rate of unscheduled PHC attendances (34.94/100 pyrs), but only 7% resulted in hospitalization. Respiratory disease was the major cause of hospitalization, unscheduled attendances and death. CD4 count <350cells/mm3 was a risk factor for hospitalization (aHR 3.6 (95%CI 1.6-8.2)).

CONCLUSIONS

Despite only 64% of participants achieving virological suppression, clinical outcomes were good and high rates of retention in care were observed. This demonstrates that in an era moving towards differentiated care in addition to implementation of universal treatment, decentralized HIV care for children is achievable. Interventions to improve adherence in this age-group are urgently needed.

Underutilisation of routinely collected data in the HIV programme in Zambia: a review of quantitatively analysed peer-reviewed articles

Background

The extent to which routinely collected HIV data from Zambia has been used in peer-reviewed published articles remains unexplored. This paper is an analysis of peer-reviewed articles that utilised routinely collected HIV data from Zambia within six programme areas from 2004 to 2014.

Methods

Articles on HIV, published in English, listed in the Directory of open access journals, African Journals Online, Google scholar, and PubMed were reviewed. Only articles from peer-reviewed journals, that utilised routinely collected data and included quantitative data analysis methods were included. Multi-country studies involving Zambia and another country, where the specific results for Zambia were not reported, as well as clinical trials and intervention studies that did not take place under routine care conditions were excluded, although community trials which referred patients to the routine clinics were included. Independent extraction was conducted using a predesigned data collection form. Pooled analysis was not possible due to diversity in topics reviewed.

Results

A total of 69 articles were extracted for review. Of these, 7 were excluded. From the 62 articles reviewed, 39 focused on HIV treatment and retention in care, 15 addressed prevention of mother-to-child transmission, 4 assessed social behavioural change, and 4 reported on voluntary counselling and testing. In our search, no articles were found on condom programming or voluntary male medical circumcision. The most common outcome measures reported were CD4+ count, clinical failure or mortality. The population analysed was children in 13 articles, women in 16 articles, and both adult men and women in 33 articles.

Conclusion

During the 10 year period of review, only 62 articles were published analysing routinely collected HIV data in Zambia. Serious consideration needs to be made to maximise the utility of routinely collected data, and to benefit from the funds and efforts to collect these data. This could be achieved with government support of operational research and publication of findings based on routinely collected Zambian HIV data.

Impact of decentralisation of antiretroviral therapy services on HIV testing and care at a population level in Agago District in rural Northern Uganda: results from the Lablite population surveys

Background

We conducted unlinked cross-sectional population-based surveys in Northern Uganda before and after antiretroviral therapy (ART) provision (including Option B+ [lifelong ART for pregnant/breast-feeding women]) at a local primary care facility (Lira Kato Health Centre [HC]). Prior to decentralisation, people travelled 56-76 km round-trip for ART; we aimed to evaluate changes in uptake of HIV-testing, ART coverage and access to ART following decentralisation.

Methods

A total of 2124 adults in 1351 households in two parishes closest to Lira Kato HC were interviewed using questionnaires between March and April 2013 and 2123 adults in 1229 households between January and March 2015.

Results

Adults reporting HIV-testing in the last year increased from 1077/2124 (50.7%) to 1298/2123 (61.1%) between surveys (p<0.001). ART coverage increased from 74/136 (54.4%) self-reported HIV-positive adults in 2013 to 108/133 (81.2%) in 2015 (p<0.001). Post-decentralisation, 47/108 (43.5%) of those on ART were in care at Lira Kato HC (including 37 new initiations). Most of the remainder (47/61, 77%) started ART prior to any ART provision at Lira Kato HC; the most common reason given for not accessing ART locally was concern about drug-stock-outs (30/59, 51%).

Conclusions

HIV-testing and ART coverage increased after decentralisation combined with Option B+ roll-out. However, patients on ART before decentralisation were reluctant to transfer to their local facility.

Mobile clinics for women's and children's health

BACKGROUND

The accessibility of health services is an important factor that affects the health outcomes of populations. A mobile clinic provides a wide range of services but in most countries the main focus is on health services for women and children. It is anticipated that improvement of the accessibility of health services via mobile clinics will improve women's and children's health.

OBJECTIVES

To evaluate the impact of mobile clinic services on women's and children's health.

SEARCH METHODS

For related systematic reviews, we searched the Database of Abstracts of Reviews of Effectiveness (DARE), CRD; Health Technology Assessment Database (HTA), CRD; NHS Economic Evaluation Database (NHS EED), CRD (searched 20 February 2014).For primary studies, we searched ISI Web of Science, for studies that have cited the included studies in this review (searched 18 January 2016); WHO ICTRP, and ClinicalTrials.gov (searched 23 May 2016); Cochrane Central Register of Controlled Trials (CENTRAL), part of The Cochrane Library. www.cochranelibrary.com (including the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register) (searched 7 April 2015); MEDLINE, OvidSP (searched 7 April 2015); Embase, OvidSP (searched 7 April 2015); CINAHL, EbscoHost (searched 7 April 2015); Global Health, OvidSP (searched 8 April 2015); POPLINE, K4Health (searched 8 April 2015); Science Citation Index and Social Sciences Citation Index, ISI Web of Science (searched 8 April 2015); Global Health Library, WHO (searched 8 April 2015); PAHO, VHL (searched 8 April 2015); WHOLIS, WHO (searched 8 April 2015); LILACS, VHL (searched 9 April 2015).

SELECTION CRITERIA

We included individual- and cluster-randomised controlled trials (RCTs) and non-RCTs. We included controlled before-and-after (CBA) studies provided they had at least two intervention sites and two control sites. Also, we included interrupted time series (ITS) studies if there was a clearly defined point in time when the intervention occurred and at least three data points before and three after the intervention. We defined the intervention of a mobile clinic as a clinic vehicle with a healthcare provider (with or without a nurse) and a driver that visited areas on a regular basis. The participants were women (18 years or older) and children (under the age of 18 years) in low-, middle-, and high-income countries.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the titles and abstracts of studies identified by the search strategy, extracted data from the included studies using a specially-designed data extraction form based on the Cochrane EPOC Group data collection checklist, and assessed full-text articles for eligibility. All authors performed analyses, 'Risk of bias' assessments, and assessed the quality of the evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

MAIN RESULTS

Two cluster-RCTs met the inclusion criteria of this review. Both studies were conducted in the USA.One study tested whether offering onsite mobile mammography combined with health education was more effective at increasing breast cancer screening rates than offering health education only, including reminders to attend a static clinic for mammography. Women in the group offered mobile mammography and health education may be more likely to undergo mammography within three months of the intervention than those in the comparison group (55% versus 40%; odds ratio (OR) 1.83, 95% CI 1.22 to 2.74; low certainty evidence).A cost-effectiveness analysis of mammography at mobile versus static units found that the total cost per patient screened may be higher for mobile units than for static units. The incremental costs per patient screened for a mobile over a stationary unit were USD 61 and USD 45 for a mobile full digital unit and a mobile film unit respectively.The second study compared asthma outcomes for children aged two to six years who received asthma care from a mobile asthma clinic and children who received standard asthma care from the usual (static) primary provider. Children who receive asthma care from a mobile asthma clinic may experience little or no difference in symptom-free days, urgent care use and caregiver-reported medication use compared to children who receive care from their usual primary care provider. All of the evidence was of low certainty.

AUTHORS' CONCLUSIONS

The paucity of evidence and the restricted range of contexts from which evidence is available make it difficult to draw conclusions on the impacts of mobile clinics on women's and children's health compared to static clinics. Further rigorous studies are needed in low-, middle-, and high-income countries to evaluate the impacts of mobile clinics on women's and children's health.

Incidence and Prevalence of Opportunistic and Other Infections and the Impact of Antiretroviral Therapy Among HIV-infected Children in Low- and Middle-income Countries: A Systematic Review and Meta-analysis

BACKGROUND

We conducted a systematic review and meta-analysis to evaluate the incidence and prevalence of 14 opportunistic infections (OIs) and other infections as well as the impact of antiretroviral therapy (ART) among human immunodeficiency virus (HIV)-infected children (aged <18 years) in low- and middle-income countries (LMICs), to understand regional burden of disease, and inform delivery of HIV services.

METHODS

Eligible studies described the incidence of OIs and other infections in ART-naive and -exposed children from January 1990 to November 2013, using Medline, Global Health, Embase, Cumulative Index to Nursing and Allied Health Literature, Web of Knowledge, and Literatura Latino Americana em Ciências da Saúde databases. Summary incident risk (IR) and prevalent risk for each OI in ART-naive and ART-exposed children were calculated, and unadjusted odds ratios calculated for impact of ART. The number of OI cases and associated costs averted were estimated using the AIDS impact model.

RESULTS

We identified 4542 citations, and 88 studies were included, comprising 55 679 HIV-infected children. Bacterial pneumonia and tuberculosis were the most common incident and prevalent infections in both ART-naive and ART-exposed children. There was a significant reduction in IR with ART for the majority of OIs. There was a smaller impact on bacterial sepsis and pneumonia, and an increase observed for varicella zoster. ART initiation based on 2010 World Health Organization guidelines criteria for ART initiation in children was estimated to potentially avert >161 000 OIs (2013 UNAIDS data) with estimated cost savings of at least US$17 million per year.

CONCLUSIONS

There is a decrease in the risk of most OIs with ART use in HIV-infected children in LMICs, and estimated large potential cost savings in OIs averted with ART use, although there are greater uncertainties in pediatric data compared with that of adults.

Lost to follow-up: failure to engage children in care in the first three months of diagnosis

Loss to follow-up (LTFU) is a critical factor in determining clinical outcomes in HIV treatment programs. Identifying modifiable factors of LTFU is fundamental for designing effective patient-retention interventions. We analyzed factors contributing to children LTFU from a treatment program to identify those that can be modified. A case-control study involving 313 children was used to compare the sociodemographic and clinical characteristics of children LTFU (cases) with those remaining in care (controls) at a large pediatric HIV care setting in Botswana. We traced children through caregiver contacts and those we found, we conducted structured interviews with patients' caregivers. Children <5 years were nearly twice as likely as older children to be LTFU (57·8% versus 30·9%, p <0 .01). Approximately half (47·6%, n = 51) of LTFU patients failed to further engage in care after just one clinic visit, as compared to less than 1% (n = 2) in the control group (p < 0.01). Children LTFU were more likely than controls to have advanced disease, greater immunosuppression, and not to be receiving antiretroviral therapy. Among interviewed patient caregivers, psychosocial factors (e.g., stigma, religious beliefs, child rebellion, disclosure of HIV status) were characteristics of patients LTFU, but not of controls. Socioeconomic factors (e.g., lack of transportation, school-related activities, forgetting appointments) were cited predominantly by the controls. Pediatric patients and their caregivers need to be targeted and engaged at their initial clinic visit, with special attention to children <5 years. Possible interventions include providing psychosocial support for issues that deter patients from engaging with The Clinic. Collaboration with community-based organizations focused on reducing stigma may be useful in addressing these complex issues.

Implementation challenges for long-acting antivirals as treatment

PURPOSE OF REVIEW

Long-acting injectable antiretroviral therapy (ART) formulations hold great promise in helping to close the significant gap between efficacy and effectiveness in HIV treatment by eliminating the requirement for lifelong daily pills. However, significant systems-level and individual challenges to implementation of long-acting ART in HIV treatment are anticipated.

RECENT FINDINGS

Studies of long-acting ART formulations are burgeoning, but the drugs are still in early phases of investigation and key knowledge gaps in pharmacokinetics and pharmacodynamics, as well as their effectiveness in settings with the largest burden of HIV disease and in key populations, remain. Extrapolating from the literature on implementation barriers to using long-acting contraception on a global scale, we explore the implementation barriers to rolling-out long-acting ART, including country approval and endorsements; prioritization of patient populations for preferred use, clinic infrastructure requirements, steady supply chains, decentralization of care, provider and patient training programs, and laboratory monitoring; and the need to examine patient preferences and conduct rigorous implementation science research to effectively scale-up this intervention.

SUMMARY

Long-acting ART for HIV treatment harbors exciting potential to shift treatment paradigms. Current knowledge gaps in the use of these agents remain, leading to multiple anticipated systems-level and individual-level barriers to implementation. Addressing these gaps and barriers will help fulfill the promise of these agents against the pandemic.

Barriers to health care in rural Mozambique: a rapid ethnographic assessment of planned mobile health clinics for ART

BACKGROUND

In Mozambique, 1.6 million people are living with HIV, and over 60% of the population lives in rural areas lacking access to health services. Mobile health clinics, implemented in 2013 in 2 provinces, are beginning to offer antiretroviral therapy (ART) and basic primary care services. Prior to introduction of the mobile health clinics in the communities, we performed a rapid ethnographic assessment to understand barriers to accessing HIV care and treatment services and acceptability and potential use of the mobile health clinics as an alternative means of service delivery.

METHODS

We conducted assessments in Gaza province in January 2013 and in Zambezia Province in April-May 2013 in districts where mobile health clinic implementation was planned. Community leaders served as key informants, and chain-referral sampling was used to recruit participants. Interviews were conducted with community leaders, health care providers, traditional healers, national health system patients, and traditional healer patients. Interviewees were asked about barriers to health services and about mobile health clinic acceptance.

RESULTS

In-depth interviews were conducted with 117 participants (Gaza province, n = 57; Zambezia Province, n = 60). Barriers to accessing health services included transportation and distance-related issues (reliability, cost, and travel time). Participants reported concurrent use of traditional and national health systems. The decision to use a particular health system depended on illness type, service distance, and lack of confidence in the national health system. Overall, participants were receptive to using mobile health clinics for their health care and ability to increase access to ART. Hesitations concerning mobile health clinics included potentially long wait times due to high patient loads. Participants emphasized the importance of regular and published visit schedules and inclusion of community members in planning mobile health clinic services.

CONCLUSION

Mobile health clinics can address many barriers to uptake of HIV services, particularly related to transportation issues. Involvement of community leaders, providers, traditional healers, and patients, as well as regularly scheduled mobile clinic visits, are critical to successful service delivery implementation in rural areas.