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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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Teeraananchai S, Kerr SJ, Ruxrungtham K, Khananuraksa P, Puthanakit T. Long-term outcomes of rapid antiretroviral NNRTI-based initiation among Thai youth living with HIV: a national registry database study. J Int AIDS Soc 2023; 26:e26071. [PMID: 36943729 PMCID: PMC10029993 DOI: 10.1002/jia2.26071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 02/17/2023] [Indexed: 03/23/2023] Open
Abstract
INTRODUCTION The Thai National AIDS programme (NAP) treatment guidelines have recommended rapid antiretroviral therapy (ART) initiation, regardless of CD4 count since 2014. We assessed treatment outcomes among youth living with HIV (YLHIV), initiating first-line ART and assessed the association between virological failure (VF) and timing of ART initiation. METHODS We retrospectively reviewed data for YLHIV aged 15-24 years, initiating non-nucleoside reverse transcriptase inhibitor-based ART from 2014 to 2019, through the NAP database. We classified the timing of ART into three groups based on duration from HIV-positive diagnosis or system registration to ART initiation: (1) <1 month (rapid ART); (2) 1-3 months (intermediate ART); and (3) >3 months (delayed ART). VF was defined as viral load (VL) ≥ 1000 copies/ml after at least 6 months of first-line ART. Factors associated with VF were analysed using generalized estimating equations. RESULTS Of 19,825 YLHIV who started ART, 78% were male. Median (interquartile range, IQR) age was 21 (20-23) years and CD4 count was 338 (187-498) cells/mm3 . After registration, 12,216 (62%) started rapid ART, 4272 (22%) intermediate ART and 3337 (17%) delayed ART. The proportion of YLHIV starting ART <30 days significantly increased from 43% to 57% from 2014-2016 to 2017-2019 (p < 0.001). The median duration of first-line therapy was 2 (IQR 1-3) years and 89% started with efavirenz-based regimens. Attrition outcomes showed that 325 (2%) died (0.73 [95% CI 0.65-0.81] per 100 person-years [PY]) and 1762 (9%) were loss to follow-up (3.96 [95% CI 3.78-4.15] per 100 PY). Of 17,512 (88%) who had VL checked from 6 to 12 months after starting treatment, 80% achieved VL <200 copies/ml. Overall, 2512 experienced VF 5.87 (95% CI 5.65-6.11) per 100 PY). In a multivariate model, the adjusted incidence rate ratio for VF was 1.47 (95% CI 1.33-1.63, p < 0.001) in the delayed ART group and 1.14 (95% CI 1.03-1.25, p< 0.001) in the intermediate ART group, compared to YLHIV in the rapid ART group. CONCLUSIONS Rapid ART initiation after diagnosis was associated with significantly reduced risks of VF and death in YLHIV, supporting the implementation of rapid ART for optimizing health outcomes.
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Affiliation(s)
- Sirinya Teeraananchai
- Department of Statistics, Faculty of Science, Kasetsart University, Bangkok, Thailand
- HIV-NAT, Thai Red Cross AIDS Research Centre, Bangkok, Thailand
| | - Stephen J Kerr
- HIV-NAT, Thai Red Cross AIDS Research Centre, Bangkok, Thailand
- Biostatistics Excellence Centre, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
| | - Kiat Ruxrungtham
- HIV-NAT, Thai Red Cross AIDS Research Centre, Bangkok, Thailand
- Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Chula Vaccine Research Center (ChulaVRC), School of Global Health, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | | | - Thanyawee Puthanakit
- Division of Infectious Diseases, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Center of Excellence in Pediatric Infectious Diseases and Vaccines, Chulalongkorn University, Bangkok, Thailand
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Murphy JP, Shumba K, Jamieson L, Nattey C, Pascoe S, Fox MP, Miot J, Maskew M. Assessment of facility-level antiretroviral treatment patient status utilizing a national-level laboratory cohort: Toward an understanding of system-level tracking and clinic switching in South Africa. Front Public Health 2022; 10:959481. [PMID: 36590005 PMCID: PMC9798405 DOI: 10.3389/fpubh.2022.959481] [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: 06/01/2022] [Accepted: 11/11/2022] [Indexed: 12/23/2022] Open
Abstract
Background Most estimates of HIV retention are derived at the clinic level through antiretroviral (ART) patient management systems, which capture ART clinic visit data, yet these cannot account for silent transfers across HIV treatment sites. Patient laboratory monitoring visits may also be observed in routinely collected laboratory data, which include ART monitoring tests such as CD4 count and HIV viral load, key to our work here. Methods In this analysis, we utilized the NHLS National HIV Cohort (a system-wide viewpoint) to investigate the accuracy of facility-level estimates of retention in care for adult patients accessing care (defined using clinic visit data on patients under ART recorded in an electronic patient management system) at Themba Lethu Clinic (TLC). Furthermore, we describe patterns of facility switching among all patients and those patients classified as lost to follow-up (LTFU) at the facility level. Results Of the 43,538 unique patients in the TLC dataset, we included 20,093 of 25,514 possible patient records (78.8%) in our analysis that were linked with the NHLS National Cohort, and we restricted the analytic sample to patients initiating ART between 1 January 2007 and 31 December 2017. Most (60%) patients were female, and the median age (IQR) at ART initiation was 37 (31-45) years. We found the laboratory records augmented retention estimates by a median of 860 additional active records (about 8% of all median active records across all years) from the facility viewpoint; this augmentation was more noticeable from the system-wide viewpoint, which added evidence of activity of about one-third of total active records in 2017. In 2017, we found 7.0% misclassification at the facility-level viewpoint, a gap which is potentially solvable through data integration/triangulation. We observed 1,134/20,093 (5.6%) silent transfers; these were noticeably more female and younger than the entire dataset. We also report the most common locations for clinic switching at a provincial level. Discussion Integration of multiple data sources has the potential to reduce the misclassification of patients as being lost to care and help understand situations where clinic switching is common. This may help in prioritizing interventions that would assist patients moving between clinics and hopefully contribute to services that normalize formal transfers and fewer silent transfers.
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Affiliation(s)
- Joshua P. Murphy
- Health Economics and Epidemiology Research Office (HERO), Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa,*Correspondence: Joshua P. Murphy
| | - Khumbo Shumba
- Health Economics and Epidemiology Research Office (HERO), Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Lise Jamieson
- Health Economics and Epidemiology Research Office (HERO), Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Cornelius Nattey
- Health Economics and Epidemiology Research Office (HERO), Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Sophie Pascoe
- Health Economics and Epidemiology Research Office (HERO), Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Matthew P. Fox
- Health Economics and Epidemiology Research Office (HERO), Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa,Department of Global Health, School of Public Health, Boston University, Boston, MA, United States
| | - Jacqui Miot
- Health Economics and Epidemiology Research Office (HERO), Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mhairi Maskew
- Health Economics and Epidemiology Research Office (HERO), Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Jonas K, Zani B, Ramraj T, Chirinda W, Jama N, Basera W, McClinton Appollis T, Pass D, Govindasamy D, Mukumbang FC, Mathews C, Nicol E. Service delivery models for enhancing linkage to and retention in HIV care services for adolescent girls and young women and adolescent boys and young men: a protocol for an overview of systematic reviews. BMJ Open 2022; 12:e060778. [PMID: 36123080 PMCID: PMC9486299 DOI: 10.1136/bmjopen-2022-060778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Recent advances in the HIV care continuum have shown that an individual diagnosed with HIV should be initiated on antiretroviral therapy as soon as possible regardless of the CD4 count levels and retained in HIV care services. Studies have reported large losses in the HIV continuum of care, before and after the era of universal test and treat. Several systematic reviews have reported on the strategies for improving linkage to and retention in HIV treatment and care. The purpose of this overview of systematic reviews is to identify HIV care interventions or service delivery models (SDMs) and synthesise evidence on the effects of these to link adolescent girls and young women (AGYW) and adolescent boys and young men (ABYM) to care and retain them in care. We also aim to highlight gaps in the evidence on interventions and SDMs to improve linkage and retention in HIV care of AGYW and ABYM. METHODS AND ANALYSIS An electronic search of four online databases: PubMed, Cochrane Database of Systematic Reviews, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Web of Science will be performed to identify systematic reviews on the effects of linkage to and retention in HIV care interventions or SDMs for AGYW aged 15-24 years and ABYM aged 15-35 years. Our findings on the effects of interventions and SDMs will be interpreted considering the intervention and or SDMs' effectiveness by the time period, setting and population of interest. Two or more authors will independently screen articles for inclusion using a priori criteria. ETHICS AND DISSEMINATION Ethics approval is not required for this study as only published secondary data will be used. Our findings will be disseminated through peer-reviewed publication, conference abstracts and through presentations to stakeholders and other community fora. The findings from this overview of systematic reviews will inform mixed-methods operations research on HIV intervention programming and delivery of HIV care services for AGYW and ABYM in South Africa. PROSPERO REGISTRATION NUMBER CRD42020177933.
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Affiliation(s)
- Kim Jonas
- Health Systems Research, South African Medical Research Council, Parow, South Africa
- Adolescent Health Research, University of Cape Town, Rondebosch, Western Cape, South Africa
| | - Babalwa Zani
- Knowledge Translation Unit, University of Cape Town Lung Institute, Rondebosch, Western Cape, South Africa
| | - Trisha Ramraj
- Health Systems Research Unit, South African Medical Research Council Durban, Durban, KwaZulu-Natal, South Africa
- HIV Prevention Research Unit, South African Medical Research Council Durban, Durban, KwaZulu-Natal, South Africa
| | - Witness Chirinda
- Burden of Disease Research, South African Medical Research Council, Tygerberg, South Africa
| | - Ngcwalisa Jama
- Burden of Disease Research, South African Medical Research Council, Tygerberg, South Africa
| | - Wisdom Basera
- Burden of Disease Research, South African Medical Research Council, Tygerberg, South Africa
| | | | - Desiree Pass
- Burden of Disease Research, South African Medical Research Council, Tygerberg, South Africa
| | - Darshini Govindasamy
- Health Systems Research, South African Medical Research Council, Parow, South Africa
| | | | - Catherine Mathews
- Health Systems Research, South African Medical Research Council, Parow, South Africa
- Adolescent Health Research, University of Cape Town, Rondebosch, Western Cape, South Africa
| | - Edward Nicol
- Burden of Disease Research, South African Medical Research Council, Tygerberg, South Africa
- University of Stellenbosch, Stellenbosch, Western Cape, South Africa
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Nardell MF, Hedt-Gauthier B, Earnshaw VA, Bogart LM, Dietrich JJ, Courtney I, Tshabalala G, Bor J, Orrell C, Gray G, Bangsberg DR, Katz IT. Understanding Repeat Positive HIV Testing in South Africa Under Changing Treatment Guidelines. AIDS Behav 2022; 26:1366-1376. [PMID: 34705150 PMCID: PMC9007825 DOI: 10.1007/s10461-021-03493-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/08/2021] [Indexed: 01/06/2023]
Abstract
Some people with HIV (PWH) test positive multiple times without initiating antiretroviral therapy (ART). We surveyed 496 ART-eligible PWH following routine HIV testing at three clinics in Soweto and Gugulethu, South Africa in 2014-2015. Among repeat positive testers (RPTs) in this cohort, we compared rates of treatment initiation by prior treatment eligibility and assessed psychosocial predictors of treatment initiation in logistic regression models. RPTs represented 33.8% of PWH in this cohort. Less than half of those who reported eligibility for ART on prior testing started treatment upon retesting, in contrast to two thirds of RPTs who were previously ineligible for treatment who started treatment once they learned of their eligibility. Those who reported coping through substance use were more likely to decline treatment versus those not using substances. PWH who test repeatedly represent a vulnerable population at risk for ART non-initiation who may benefit from interventions addressing individualized coping strategies.
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Affiliation(s)
- Maria F Nardell
- Division of Global Health Equity, Brigham and Women's Hospital, Thorn Building 14th Floor, Boston, MA, 02120, USA.
- Harvard Medical School, Boston, USA.
- Department of Medicine, Brigham and Women's Hospital, Boston, USA.
| | - Bethany Hedt-Gauthier
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA
- Massachusetts General Hospital Center for Global Health, Boston, USA
| | - Valerie A Earnshaw
- Department of Human Development and Family Sciences, University of Delaware, Newark, USA
| | | | - Janan J Dietrich
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- Health Systems Research Unit, South African Medical Research Council, Western Cape, South Africa
| | - Ingrid Courtney
- Desmond Tutu Health Foundation, University of Cape Town Medical School, Cape Town, South Africa
| | - Gugulethu Tshabalala
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Jacob Bor
- Department of Global Health, Boston University School of Public Health, Boston, USA
| | - Catherine Orrell
- Desmond Tutu Health Foundation, University of Cape Town Medical School, Cape Town, South Africa
| | - Glenda Gray
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- Office of the President, South African Medical Research Council, Western Cape, South Africa
| | - David R Bangsberg
- Oregon Health & Science University-Portland State University School of Public Health, Portland, USA
| | - Ingrid T Katz
- Harvard Medical School, Boston, USA
- Department of Medicine, Brigham and Women's Hospital, Boston, USA
- Massachusetts General Hospital Center for Global Health, Boston, USA
- Harvard Global Health Institute, Cambridge, USA
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Harrison MJ, Brice N, Scott C. Clinical Features of HIV Arthropathy in Children: A Case Series and Literature Review. Front Immunol 2021; 12:677984. [PMID: 34354702 PMCID: PMC8329591 DOI: 10.3389/fimmu.2021.677984] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 07/02/2021] [Indexed: 12/02/2022] Open
Abstract
Background HIV infection has been associated with a non-erosive inflammatory arthritis in children, although few published reports exist. This study describes the clinical, laboratory and imaging features of this noncommunicable disease in a series of HIV-infected children in South Africa. Methods A database search was conducted to identify HIV-infected children enrolled in a Paediatric Rheumatology service in Cape Town, South Africa between 1 January 2010 and 31 December 2020. Retrospective data were collected from individuals classified with HIV arthropathy, based on a predefined checklist. Demographic, clinical, laboratory, sonographic, therapeutic, and outcomes data were extracted by chart review. Descriptive statistical analysis was performed using R (v4.0.3). Results Eleven cases of HIV arthropathy were included in the analysis. Cases predominantly presented in older boys with low CD4+ counts. Median age at arthritis onset was 10.3 years (IQR 6.9 – 11.6) and the male-female ratio was 3.0. The median absolute CD4+ count was 389 cells/uL (IQR 322 – 449). The clinical presentation was variable, with both oligoarthritis and polyarthritis being common. Elevated acute phase reactants were the most consistent laboratory feature, with a median ESR of 126 mL/h (IQR 67 – 136) and median CRP of 36 mg/L (IQR 25 – 68). Ultrasonography demonstrated joint effusions and synovial hypertrophy. Response to therapy was slower than has generally been described in adults, with almost all cases requiring more than one immunosuppressive agent. Five children were discharged in established remission after discontinuing immunotherapy, however outcomes data were incomplete for the remaining six cases. Conclusions In this case series, HIV arthropathy was associated with advanced immunosuppression. Therapeutic modalities included immunomodulators and antiretroviral therapy, which consistently induced disease remission although data were limited by a high rate of attrition. Prospective studies are needed to define and understand this HIV-associated noncommunicable disease.
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Affiliation(s)
- Michael J Harrison
- Fort Beaufort Provincial Hospital, Amathole District, Eastern Cape, South Africa
| | - Nicola Brice
- Division of Paediatric Rheumatology, Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital, Cape Town, South Africa.,University of Cape Town, Rondebosch, Cape Town, South Africa
| | - Christiaan Scott
- Division of Paediatric Rheumatology, Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital, Cape Town, South Africa.,University of Cape Town, Rondebosch, Cape Town, South Africa
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Mugglin C, Kläger D, Gueler A, Vanobberghen F, Rice B, Egger M. The HIV care cascade in sub-Saharan Africa: systematic review of published criteria and definitions. J Int AIDS Soc 2021; 24:e25761. [PMID: 34292649 PMCID: PMC8297382 DOI: 10.1002/jia2.25761] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 05/14/2021] [Accepted: 05/25/2021] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION The HIV care cascade examines the attrition of people living with HIV from diagnosis to the use of antiretroviral therapy (ART) and suppression of viral replication. We reviewed the literature from sub-Saharan Africa to assess the definitions used for the different steps in the HIV care cascade. METHODS We searched PubMed, Embase and CINAHL for articles published from January 2004 to December 2020. Longitudinal and cross-sectional studies were included if they reported on at least one step of the UNAIDS 90-90-90 cascade or two steps of an extended 7-step cascade. A step was clearly defined if authors reported definitions for numerator and denominator, including the description of the eligible population and methods of assessment or measurement. The review protocol has been published and registered in Prospero. RESULTS AND DISCUSSION Overall, 3364 articles were screened, and 82 studies from 19 countries met the inclusion criteria. Most studies were from Southern (38 studies, 34 from South Africa) and East Africa (29 studies). Fifty-eight studies (71.6%) were longitudinal, with a median follow-up of three years. The medium number of steps covered out of 7 steps was 3 (interquartile range [IQR] 2 to 4); the median year of publication was 2015 (IQR 2013 to 2019). The number of different definitions for the numerators ranged from four definitions (for step "People living with HIV") to 21 (step "Viral suppression"). For the denominators, it ranged from three definitions ("Diagnosed and aware of HIV status") to 14 ("Viral suppression"). Only 12 studies assessed all three of the 90-90-90 steps. Most studies used longitudinal data, but denominator-denominator or denominator-numerator linkages over several steps were rare. Also, cascade data are lacking for many countries. Our review covers the academic literature but did not consider other data, such as government reports on the HIV care cascade. Also, it did not examine disengagement and reengagement in care. CONCLUSIONS The proportions of patients retained at each step of the HIV care cascade cannot be compared between studies, countries and time periods, nor meta-analysed, due to the many different definitions used for numerators and denominators. There is a need for standardization of methods and definitions.
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Affiliation(s)
- Catrina Mugglin
- Institute of Social and Preventive Medicine (ISPM)University of BernBernSwitzerland
| | - Delia Kläger
- Institute of Social and Preventive Medicine (ISPM)University of BernBernSwitzerland
| | - Aysel Gueler
- Institute of Social and Preventive Medicine (ISPM)University of BernBernSwitzerland
| | - Fiona Vanobberghen
- Faculty of Epidemiology and Population HealthLondon School of Hygiene and Tropical MedicineLondonUK
- Swiss Tropical and Public Health InstituteBaselSwitzerland
- University of BaselBaselSwitzerland
| | - Brian Rice
- Faculty of Epidemiology and Population HealthLondon School of Hygiene and Tropical MedicineLondonUK
| | - Matthias Egger
- Institute of Social and Preventive Medicine (ISPM)University of BernBernSwitzerland
- Centre for Infectious Disease Epidemiology and Research (CIDER)University of Cape TownCape TownSouth Africa
- Population Health SciencesBristol Medical SchoolUniversity of BristolBristolUK
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Limbada M, Zijlstra G, Macleod D, Ayles H, Fidler S. A systematic review of the effectiveness of non- health facility based care delivery of antiretroviral therapy for people living with HIV in sub-Saharan Africa measured by viral suppression, mortality and retention on ART. BMC Public Health 2021; 21:1110. [PMID: 34112135 PMCID: PMC8194040 DOI: 10.1186/s12889-021-11053-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Accepted: 05/12/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Alternative models for sustainable antiretroviral treatment (ART) delivery are necessary to meet the increasing demand to maintain population-wide ART for all people living with HIV (PLHIV) in sub-Saharan Africa. We undertook a review of published literature comparing health facility-based care (HFBC) with non-health facility based care (nHFBC) models of ART delivery in terms of health outcomes; viral suppression, loss to follow-up, retention and mortality. METHODS We conducted a systematic search of Medline, Embase and Global Health databases from 2010 onwards. UNAIDS reports, WHO guidelines and abstracts from conferences were reviewed. All studies measuring at least one of the following outcomes, viral load suppression, loss-to-follow-up (LTFU) and mortality were included. Data were extracted, and a descriptive analysis was performed. Risk of bias assessment was done for all studies. Pooled estimates of the risk difference (for viral suppression) and hazard ratio (for mortality) were made using random-effects meta-analysis. RESULTS Of 3082 non-duplicate records, 193 were eligible for full text screening of which 21 published papers met the criteria for inclusion. The pooled risk difference of viral load suppression amongst 4 RCTs showed no evidence of a difference in viral suppression (VS) between nHFBC and HFBC with an overall estimated risk difference of 1% [95% CI -1, 4%]. The pooled hazard ratio of mortality amongst 2 RCTs and 4 observational cohort studies showed no evidence of a difference in mortality between nHFBC and HFBC with an overall estimated hazard ratio of 1.01 [95% CI 0.88, 1.16]. Fifteen studies contained data on LTFU and 13 studies on retention. Although no formal quantitative analysis was performed on these outcomes due to the very different definitions between papers, it was observed that the outcomes appeared similar between HFBC and nHFBC. CONCLUSIONS Review of current literature demonstrates comparable outcomes for nHFBC compared to HFBC ART delivery programmes in terms of viral suppression, retention and mortality. PROSPERO NUMBER CRD42018088194 .
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Affiliation(s)
- Mohammed Limbada
- Zambart House, PO Box 50697, UNZA-Ridgeway Campus, Lusaka, Zambia.
| | | | - David Macleod
- MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
| | - Helen Ayles
- Zambart House, PO Box 50697, UNZA-Ridgeway Campus, Lusaka, Zambia
- MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
| | - Sarah Fidler
- Imperial College and Imperial college NIHR BRC, London, UK
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Katz IT, Bogart LM, Fitzmaurice GM, Staggs VS, Gwadz MV, Bassett IV, Cross A, Courtney I, Tsolekile L, Panda R, Steck S, Bangsberg DR, Orrell C, Goggin K. The Treatment Ambassador Program: A Highly Acceptable and Feasible Community-Based Peer Intervention for South Africans Living with HIV Who Delay or Discontinue Antiretroviral Therapy. AIDS Behav 2021; 25:1129-1143. [PMID: 33125587 PMCID: PMC7979476 DOI: 10.1007/s10461-020-03063-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/08/2020] [Indexed: 12/18/2022]
Abstract
We conducted a novel pilot randomized controlled trial of the Treatment Ambassador Program (TAP), an 8-session, peer-based, behavioral intervention for people with HIV (PWH) in South Africa not on antiretroviral therapy (ART). PWH (43 intervention, 41 controls) completed baseline, 3- and 6-month assessments. TAP was highly feasible (90% completion), with peer counselors demonstrating good intervention fidelity. Post-intervention interviews showed high acceptability of TAP and counselors, who supported autonomy, assisted with clinical navigation, and provided psychosocial support. Intention-to-treat analyses indicated increased ART initiation by 3 months in the intervention vs. control arm (12.2% [5/41] vs. 2.3% [1/43], Fisher exact p-value = 0.105; Cohen's h = 0.41). Among those previously on ART (off for > 6 months), 33.3% initiated ART by 3 months in the intervention vs. 14.3% in the control arm (Cohen's h = 0.45). Results suggest that TAP was highly acceptable and feasible among PWH not on ART.
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Affiliation(s)
- Ingrid T Katz
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
- Massachusetts General Hospital Center for Global Health, Boston, MA, USA.
- Harvard Global Health Institute, Cambridge, MA, USA.
- Division of Women's Health, Brigham and Women's Hospital, 1620 Tremont St. - 3rd Floor, Boston, MA, 02120, USA.
| | | | - Garrett M Fitzmaurice
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Laboratory for Psychiatric Biostatistics, McLean Hospital, Belmont, MA, USA
| | - Vincent S Staggs
- Health Services and Outcomes Research, Children's Mercy Kansas City, Kansas City, MO, USA
- School of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Marya V Gwadz
- Silver School of Social Work, New York University, New York, NY, USA
| | - Ingrid V Bassett
- Harvard Medical School, Boston, MA, USA
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Anna Cross
- Desmond Tutu HIV Foundation, University of Cape Town Medical School, Cape Town, South Africa
| | - Ingrid Courtney
- Desmond Tutu HIV Foundation, University of Cape Town Medical School, Cape Town, South Africa
| | - Lungiswa Tsolekile
- School of Public Health, University of the Western Cape, Cape Town, South Africa
| | - Regina Panda
- Desmond Tutu HIV Foundation, University of Cape Town Medical School, Cape Town, South Africa
| | - Sonja Steck
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - David R Bangsberg
- Oregon Health & Science University-Portland State University School of Public Health, Portland, OR, USA
| | - Catherine Orrell
- Desmond Tutu HIV Foundation, University of Cape Town Medical School, Cape Town, South Africa
| | - Kathy Goggin
- Health Services and Outcomes Research, Children's Mercy Kansas City, Kansas City, MO, USA
- School of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA
- School of Pharmacy, University of Missouri-Kansas City, Kansas City, MO, USA
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10
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Zanoni BC, Haberer JE. The Meaning of "Rapid" Antiretroviral Therapy Initiation for Adolescents With Human Immunodeficiency Virus in Sub-Saharan Africa. J Infect Dis 2021; 222:705-707. [PMID: 31682259 DOI: 10.1093/infdis/jiz548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 10/28/2019] [Indexed: 11/14/2022] Open
Affiliation(s)
- Brian C Zanoni
- Emory University School of Medicine, Atlanta, Georgia, USA
| | - Jessica E Haberer
- Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
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11
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Teeraananchai S, Kerr SJ, Khananuraksa P, Ruxrungtham K, Puthanakit T. Rapid antiretroviral initiation among Thai youth living with HIV in the National AIDS programme in the era of treatment at any CD4 cell count: a national registry database study. J Int AIDS Soc 2020; 23 Suppl 5:e25574. [PMID: 32869537 PMCID: PMC7459169 DOI: 10.1002/jia2.25574] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 05/24/2020] [Accepted: 06/19/2020] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION The process indicators of ending the HIV epidemic include 90% of people living with HIV receiving antiretroviral therapy (ART). The population of youth, however, has less access to healthcare. We assessed ART initiation and attrition outcomes of the HIV continuum from HIV diagnosis to ART initiation in youth living with HIV (YLHIV) and factors associated with ART initiation. METHODS We studied YLHIV aged 15 to 24 years who were registered on the National AIDS Program (NAP) from January 2008 to May 2019. The study period was divided into 2008 to 2013 (initiated ART by CD4-guided criteria) and 2014 to 2018 (initiate ART at any CD4). Date of registration was used as a surrogate for the diagnosis date and defined as the baseline. The database included ART prescription and laboratory results, and the vital status was linked daily with the National Death Registry. Competing risk methods were used to assess factors associated with accessing ART, with loss to follow-up (LTFU) and death considered as competing events. Logistic regression was used to assess factors associated with rapid ART initiation, defined as initiation ≤1 month after registration. RESULTS Overall, 51,607 youth registered on the NAP (42% between 2008 and 2013). Median age was 21 (IQR 20 to 23) years; 64% were male. Overall ART initiation was 80% in the first period and 83% in the second. The ART initiation rate was higher among YLHIV aged 15 to 19 years (86%) than 20 to 24 years (82%) (p < 0.001) in the second period. The proportion of youth starting rapid ART increased significantly from 27% to 52% between the two periods (p < 0.001). Factors associated with ART initiation were age 15 to 19 years (aSHR 1.09, 95% CI 1.06 to 1.11), female (aSHR 1.26, 95% CI 1.23 to 1.29) and registration year 2014 to 2018 (aSHR 1.73, 95% CI 1.69 to 1.76). The cumulative incidence of LTFU/death prior to ART initiation at 12 months was 3.8% (95% CI 3.6% to 4.1%) in the first period and 1.9% (95% CI 1.8% to 2.1%) in the second period. CONCLUSIONS In the era of universal treatment of all at any CD4 level, 83% of YLHIV registered on the Thai National AIDS Program initiated ART. The majority initiated within one month of registration.
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Affiliation(s)
- Sirinya Teeraananchai
- HIV‐NATThai Red Cross AIDS Research CentreBangkokThailand
- Department of StatisticsFaculty of ScienceKasetsart UniversityBangkokThailand
| | - Stephen J Kerr
- HIV‐NATThai Red Cross AIDS Research CentreBangkokThailand
- Biostatistics Excellence CentreFaculty of MedicineChulalongkorn UniversityBangkokThailand
- Kirby InstituteUniversity of New South WalesSydneyAustralia
| | | | - Kiat Ruxrungtham
- HIV‐NATThai Red Cross AIDS Research CentreBangkokThailand
- Department of MedicineFaculty of MedicineChulalongkorn UniversityBangkokThailand
| | - Thanyawee Puthanakit
- HIV‐NATThai Red Cross AIDS Research CentreBangkokThailand
- Division of Infectious DiseasesDepartment of PediatricsFaculty of MedicineChulalongkorn UniversityBangkokThailand
- Center of Excellence in Pediatric Infectious Diseases and VaccinesChulalongkorn UniversityBangkokThailand
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12
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Pascoe SJS, Scott NA, Fong RM, Murphy J, Huber AN, Moolla A, Phokojoe M, Gorgens M, Rosen S, Wilson D, Pillay Y, Fox MP, Fraser‐Hurt N. "Patients are not the same, so we cannot treat them the same" - A qualitative content analysis of provider, patient and implementer perspectives on differentiated service delivery models for HIV treatment in South Africa. J Int AIDS Soc 2020; 23:e25544. [PMID: 32585077 PMCID: PMC7316408 DOI: 10.1002/jia2.25544] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 04/15/2020] [Accepted: 05/08/2020] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION In 2014, the South African government adopted a differentiated service delivery (DSD) model in its "National Adherence Guidelines for Chronic Diseases (HIV, TB and NCDs)" (AGL) to strengthen the HIV care cascade. We describe the barriers and facilitators of the AGL implementation as experienced by various stakeholders in eight intervention and control sites across four districts. METHODS Embedded within a cluster-randomized evaluation of the AGL, we conducted 48 in-depth interviews (IDIs) with healthcare providers, 16 IDIs with Department of Health and implementing partners and 24 focus group discussions (FGDs) with three HIV patient groups: new, stable and those not stable on treatment or not adhering to care. IDIs were conducted from August 2016 to August 2017; FGDs were conducted in January to February 2017. Content analysis was guided by the Consolidated Framework for Implementation Research. Findings were triangulated among respondent types to elicit barriers and facilitators to implementation. RESULTS New HIV patients found counselling helpful but intervention respondents reported sub-optimal counselling and privacy concerns as barriers to initiation. Providers felt insufficiently trained for this intervention and were confused by the simultaneous rollout of the Universal Test and Treat strategy. For stable patients, repeat prescription collection strategies (RPCS) were generally well received. Patients and providers concurred that RPCS reduced congestion and waiting times at clinics. There was confusion though, among providers and implementers, around implementation of RPCS interventions. For patients not stable on treatment, enhanced counselling and tracing patients lost-to-follow-up were perceived as beneficial to adherence behaviours but faced logistical challenges. All providers faced difficulties accessing data and identifying patients in need of tracing. Congestion at clinics and staff attitude were perceived as barriers preventing patients returning to care. CONCLUSIONS Implementation of DSD models at scale is complex but this evaluation identified several positive aspects of AGL implementation. The positive perception of RPCS interventions and challenges managing patients not stable on treatment aligned with results from the larger evaluation. While some implementation challenges may resolve with experience, ensuring providers and implementers have the necessary training, tools and resources to operationalize AGL effectively is critical to the overall success of South Africa's HIV control strategy.
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Affiliation(s)
- Sophie J S Pascoe
- Health Economics and Epidemiology Research OfficeDepartment of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Nancy A Scott
- Department of Global HealthBoston University School of Public HealthBostonMAUSA
| | - Rachel M Fong
- Department of Global HealthBoston University School of Public HealthBostonMAUSA
| | - Joshua Murphy
- Health Economics and Epidemiology Research OfficeDepartment of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Amy N Huber
- Health Economics and Epidemiology Research OfficeDepartment of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Aneesa Moolla
- Health Economics and Epidemiology Research OfficeDepartment of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | | | | | - Sydney Rosen
- Health Economics and Epidemiology Research OfficeDepartment of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
- Department of Global HealthBoston University School of Public HealthBostonMAUSA
| | | | - Yogan Pillay
- National Department of HealthPretoriaSouth Africa
| | - Matthew P Fox
- Health Economics and Epidemiology Research OfficeDepartment of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
- Department of Global HealthBoston University School of Public HealthBostonMAUSA
- Department of EpidemiologyBoston University School of Public HealthBostonMAUSA
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13
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Kaplan S, Nteso KS, Ford N, Boulle A, Meintjes G. Loss to follow-up from antiretroviral therapy clinics: A systematic review and meta-analysis of published studies in South Africa from 2011 to 2015. South Afr J HIV Med 2019; 20:984. [PMID: 31956435 PMCID: PMC6956684 DOI: 10.4102/sajhivmed.v20i1.984] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 08/20/2019] [Indexed: 11/05/2022] Open
Abstract
Background South Africa has the largest antiretroviral therapy (ART) programme in the world. To optimise programme outcomes, it is critical that patients are retained in care and that retention is accurately measured. Objectives To identify all studies published in South Africa from 2011 to 2015 that used loss to follow-up (LTFU) as an indicator or outcome to describe the variation in definitions and to estimate the proportion of patients lost to care across studies. Method All studies published between 01 January 2011 and October 2015 that included loss to follow-up or default from ART care in a South African cohort were included by use of a broad search strategy across multiple databases. To be included, the cohort had to include any patient ART data, including follow-up time, from 01 January 2010. Two authors, working independently, extracted data and assessed risk of bias from all manuscripts. Meta-analysis was performed for studies stratified by the same loss to follow-up definition. Results Forty-eight adult, 15 paediatric and 4 pregnant cohorts were included. Median cohort size was 3737; follow-up time ranged from 9 weeks to 5 years. Meta-analysis did not reveal an important difference in LTFU estimates in adult cohorts at 1 year between loss to follow-up defined as 3 months (11.0%, n = 4; 95% CI 10.7% – 11.2%) compared with 6 months (12.0%, n = 4; 95% CI 11.8% – 12.2%). Only two cohorts reported reliable LTFU estimates at 5 years: this was 25.1% (95% CI 24.8% – 25.4%). Conclusion South Africa should standardise a LTFU definition. This would aid in monitoring and evaluation of ART programmes, with the broader goal of improving patient outcomes.
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Affiliation(s)
- Samantha Kaplan
- Department of Internal Medicine, University of Washington, Seattle, United States
| | - Katleho S Nteso
- Medical Care Development International, Maseru, Lesotho, South Africa.,School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Nathan Ford
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Andrew Boulle
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Graeme Meintjes
- Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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14
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Koduah Owusu K, Adu-Gyamfi R, Ahmed Z. Strategies To Improve Linkage To HIV Care In Urban Areas Of Sub-Saharan Africa: A Systematic Review. HIV AIDS (Auckl) 2019; 11:321-332. [PMID: 31819663 PMCID: PMC6898990 DOI: 10.2147/hiv.s216093] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2019] [Accepted: 09/05/2019] [Indexed: 12/17/2022] Open
Abstract
Of the 37 million people estimated to be living with HIV globally in 2017, about 24.7 million were in the sub-Saharan Africa region, which has been and remains worst affected by the epidemic. Enrolment of newly diagnosed individuals into care in the region, however, remains poor with up to 54% not being linked to care. Linkage to care is a very important step in the HIV cascade as it is the precursor to initiating antiretroviral therapy (ART), retention in care, and viral suppression. A systematic review was conducted to gather information regarding the strategies that have been documented to increase linkage to care of Persons living with HIV(PLHIV) in urban areas of sub-Saharan Africa. An electronic search was conducted on Scopus, Cochrane central, CINAHL Plus, PubMed and OpenGrey for linkage strategies implemented from 2006. A total of 189 potentially relevant citations were identified, of which 7 were eligible for inclusion. The identified strategies were categorized using themes from literature. The most common strategies included: health system interventions (i.e. comprehensive care, task shifting); patient convenience and accessibility (i.e. immediate CD4 count testing, immediate ART initiation, community HIV testing); behavior interventions and peer support (i.e. assisted partner services, care facilitation, mobile phone appointment reminders, health education) and incentives (i.e. non-cash financial incentives and transport reimbursement). Several strategies showed favorable outcomes: comprehensive care, immediate CD4 count testing, immediate ART initiation, and assisted partner services. Assisted partner services, same day home-based ART initiation, combination intervention strategies and point-of-care CD4 testing significantly improved linkage to care in urban settings of sub-Saharan African region. They can be delivered either in a health facility or in the community but should be facilitated by health workers. There is, however, the need to conduct more linkage-specific studies in the sub-region.
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Affiliation(s)
- Kwadwo Koduah Owusu
- School of Life and Medical Sciences, University of Hertfordshire, Hertfordshire, UK
| | - Raphael Adu-Gyamfi
- National AIDS/STI Control Programme, Ghana Health Service, Korle-Bu, Accra, Ghana
| | - Zamzam Ahmed
- School of Life and Medical Sciences, University of Hertfordshire, Hertfordshire, UK
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15
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Continuum of HIV Care in Rural Mozambique: The Implications of HIV Testing Modality on Linkage and Retention. J Acquir Immune Defic Syndr 2019; 78:527-535. [PMID: 29771786 PMCID: PMC6075879 DOI: 10.1097/qai.0000000000001720] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Supplemental Digital Content is Available in the Text. Introduction: Context-specific improvements in the continuum of HIV care are needed to achieve the UNAIDS target of 90-90-90. This study aimed to assess the linkage to and retention in HIV care according to different testing modalities in rural southern Mozambique. Methods: Adults newly diagnosed with HIV from voluntary counseling and testing, provider-initiated counseling and testing, and home-based HIV testing services were prospectively enrolled between 2014 and 2015 at the Manhiça District. Patients were passively followed up through chart examination. Tracing was performed at 12 months to ascertain causes of loss to follow-up. Fine and Gray competing risk analysis was performed to determine factors associated with the each step of the cascade. Results: Overall linkage to care as defined by having a CD4 count at 3 months was 43.7% [95% confidence interval (CI): 40.8 to 46.6] and 25.2% of all participants initiated antiretroviral therapy. Factors associated with increased linkage in multivariable analysis included testing at voluntary counseling and testing, older age, having been previously tested for HIV, owning a cell phone, presenting with WHO clinical stages III/IV, self-reported illness-associated disability in the previous month, and later calendar month of participant recruitment. Ascertaining deaths and transfers allowed for adjustment of the rate of 12-month retention in treatment from 75.6% (95% CI: 70.2 to 80.5) to 84.2% (95% CI: 79.2 to 88.5). Conclusions: Home-based HIV testing reached a sociodemographically distinct population from that of clinic-based testing modalities but low linkage to care points to a need for facilitated linkage interventions. Distinguishing between true treatment defaulting and other causes of loss to follow-up can significantly change indicators of retention in care.
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16
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DiAndreth L, Krishnan N, Elf JL, Cox S, Tilchin C, Nthulana M, Jarrett B, Kronis N, Dupuis E, Motlhaoleng K, Chon S, Martinson N, Golub JE. Formative research for an mHealth program to improve the HIV care continuum in South Africa. AIDS Care 2019; 32:744-748. [PMID: 31298566 DOI: 10.1080/09540121.2019.1640850] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
In South Africa, high attrition rates throughout the care continuum present major barriers to controlling the HIV epidemic. Mobile health (mHealth) interventions may provide innovative opportunities for efficient healthcare delivery and improving retention in care. In this formative research, we interviewed 11 patients and 28 healthcare providers in North West Province, South Africa, to identify perceived benefits, concerns and suggestions for a future mHealth program to deliver HIV Viral Load and CD4 Count test results directly to patients via mobile phone. Thematic analysis found that reduced workload for providers, reduced wait times for patients, potential expanded uses and patient empowerment were the main perceived benefits of an mHealth program. Perceived concerns included privacy, disseminating distressing results through text messages and patients' inability to interpret results. Participants felt that an mHealth program should complement face-to-face interactions and educational information to interpret results is needed. Providers identified logistical considerations and suggested protocols be developed. An mHealth program to deliver HIV test results directly to patients could mitigate multiple barriers to care but needs to be tested for efficacy. Concerns identified by patients and providers must be addressed in designing the program to successfully integrate with health facility workflow and ensure its sustainability.
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Affiliation(s)
- Lisa DiAndreth
- Johns Hopkins School of Nursing, Baltimore, MD, USA.,Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Nandita Krishnan
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Jessica L Elf
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sarah Cox
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Carla Tilchin
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Munei Nthulana
- Perinatal HIV Research Unit, Chris Hani Baragwanath Hospital, Soweto, South Africa
| | - Brooke Jarrett
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Nadya Kronis
- Johns Hopkins School of Nursing, Baltimore, MD, USA
| | - Elisa Dupuis
- Johns Hopkins School of Nursing, Baltimore, MD, USA.,Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Katlego Motlhaoleng
- Perinatal HIV Research Unit, Chris Hani Baragwanath Hospital, Soweto, South Africa
| | - Sandy Chon
- Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Neil Martinson
- Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Perinatal HIV Research Unit, Chris Hani Baragwanath Hospital, Soweto, South Africa
| | - Jonathan E Golub
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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17
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Fox MP, Pascoe S, Huber AN, Murphy J, Phokojoe M, Gorgens M, Rosen S, Wilson D, Pillay Y, Fraser-Hurt N. Adherence clubs and decentralized medication delivery to support patient retention and sustained viral suppression in care: Results from a cluster-randomized evaluation of differentiated ART delivery models in South Africa. PLoS Med 2019; 16:e1002874. [PMID: 31335865 PMCID: PMC6650049 DOI: 10.1371/journal.pmed.1002874] [Citation(s) in RCA: 71] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 06/28/2019] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Differentiated antiretroviral therapy (ART) delivery models, in which patients are provided with care relevant to their current status (e.g., newly initiating, stable on treatment, or unstable on treatment) has become an essential part of patient-centered health systems. In 2015, the South African government implemented Chronic Disease Adherence Guidelines (AGLs), which involved five interventions: Fast Track Initiation Counseling for newly initiating patients, Enhanced Adherence Counseling for patients with an unsuppressed viral load, Early Tracing of patients who miss visits, and Adherence Clubs (ACs) and Decentralized Medication Delivery (DMD) for stable patients. We evaluated two of these interventions in 24 South African facilities: ACs, in which patients meet in groups outside usual clinic procedures and receive medication; and DMD, in which patients pick up their medication outside usual pharmacy queues. METHODS AND FINDINGS We compared those participating in ACs or receiving DMD at intervention sites to those eligible for ACs or DMD at control sites. Outcomes were retention and sustained viral suppression (<400 copies/mL) 12 months after AC or DMD enrollment (or comparable time for controls). 12 facilities were randomly allocated to intervention and 12 to control arms in four provinces (Gauteng, North West, Limpopo, and KwaZulu Natal). We calculated adjusted risk differences (aRDs) with cluster adjustment using generalized estimating equations (GEEs) using difference in differences (DiD) with patients eligible for ACs/DMD prior to implementation (Jan 1, 2015) for comparison. For DMD, randomization was not preserved, and the analysis was treated as observational. For ACs, 275 intervention and 294 control patients were enrolled; 72% of patients were female, 61% were aged 30-49 years, and median CD4 count at ART initiation was 268 cells/μL. AC patients had higher 1-year retention (89.5% versus 81.6%, aRD: 8.3%; 95% CI: 1.1% to 15.6%) and comparable sustained 1-year viral suppression (<400 copies/mL any time ≤ 18 months) (80.0% versus 79.6%, aRD: 3.8%; 95% CI: -6.9% to 14.4%). Retention associations were apparently stronger for men than women (men RD: 13.1%, 95% CI: 0.3% to 23.5%; women RD: 6.0%, 95% CI: -0.9% to 12.9%). For DMD, 232 intervention and 346 control patients were enrolled; 71% of patients were female, 65% were aged 30-49 years, and median CD4 count at ART initiation was 270 cells/μL. DMD patients had apparently lower retention (81.5% versus 87.2%, aRD: -5.9%; 95% CI: -12.5% to 0.8%) and comparable viral suppression versus standard of care (77.2% versus 74.3%, aRD: -1.0%; 95% CI: -12.2% to 10.1%), though in both cases, our findings were imprecise. We also noted apparently increased viral suppression among men (RD: 11.1%; 95% CI: -3.4% to 25.5%). The main study limitations were missing data and lack of randomization in the DMD analysis. CONCLUSIONS In this study, we found comparable DMD outcomes versus standard of care at facilities, a benefit for retention of patients in care with ACs, and apparent benefits in terms of retention (for AC patients) and sustained viral suppression (for DMD patients) among men. This suggests the importance of alternative service delivery models for men and of community-based strategies to decongest primary healthcare facilities. Because these strategies also reduce patient inconvenience and decongest clinics, comparable outcomes are a potential success. The cost of all five AGL interventions and possible effects on reducing clinic congestion should be investigated. CLINICAL TRIAL REGISTRATION NCT02536768.
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Affiliation(s)
- Matthew P. Fox
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, United States of America
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- * E-mail:
| | - Sophie Pascoe
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Amy N. Huber
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Joshua Murphy
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | | | - Sydney Rosen
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - David Wilson
- The World Bank Group, Washington DC, United States of America
| | - Yogan Pillay
- National Department of Health, Pretoria, South Africa
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18
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Katz IT, Bogart LM, Dietrich JJ, Leslie HH, Iyer HS, Leone D, Magidson JF, Earnshaw VA, Courtney I, Tshabalala G, Fitzmaurice GM, Orrell C, Gray G, Bangsberg DR. Understanding the role of resilience resources, antiretroviral therapy initiation, and HIV-1 RNA suppression among people living with HIV in South Africa: a prospective cohort study. AIDS 2019; 33 Suppl 1:S71-S79. [PMID: 31397725 PMCID: PMC6712569 DOI: 10.1097/qad.0000000000002175] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
OBJECTIVE Failure to initiate antiretroviral therapy (ART) and achieve virologic suppression are significant barriers to the United Nations 90-90-90 goals. Identifying resilience resources, or modifiable strength-based factors, among people living with HIV is critical for successful HIV treatment and prevention. DESIGN Prospective cohort study. METHODS From July 2014 to July 2015, 500 adults presenting for voluntary counseling and HIV testing who were diagnosed with HIV and were ART-eligible in South Africa (Soweto and Gugulethu) were enrolled and surveyed. Logistic regression models assessed resilience-related predictors of ART initiation within 6 months of voluntary counseling and HIV testing for HIV, and HIV-1 plasma RNA suppression within 9 months, adjusting for sociodemographic factors. RESULTS Within 6 months, 62% initiated ART, and within 9 months, 25% had evidence of an undetectable HIV-1 plasma RNA (<50 copies/ml). Participants who initiated ART relied less on social support from friends [adjusted odds ratio (aOR) 0.94, 95% confidence interval (CI): 0.89-0.99], coped using self-distraction (aOR 1.05, 95% CI: 1.00-1.10) and avoided coping through substance use (aOR 0.79, 95% CI: 0.65-0.97), as compared with participants who did not initiate ART. Those who achieved plasma RNA suppression relied more on social support from a significant other/partner (aOR 1.04, 95% CI: 1.02-1.07), used positive religious coping (aOR 1.03, 95% CI: 1.00-1.07), and were less likely to engage in denial coping (aOR 0.84, 95% CI: 0.77-0.92), compared with those who initiated ART but did not achieve plasma RNA suppression. CONCLUSION Interventions optimizing resilience resources and decreasing maladaptive coping strategies (e.g., substance use, denial) may present a feasible approach to maximizing ART-based HIV treatment strategies among South African people living with HIV.
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Affiliation(s)
- Ingrid T. Katz
- Department of Medicine, Brigham and Women’s Hospital
- Harvard Medical School
- Massachusetts General Hospital Center for Global Health, Boston
- Harvard Global Health Institute, Cambridge, Massachusetts
| | | | - Janan J. Dietrich
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | | | - Dominick Leone
- Department of Medicine, Brigham and Women’s Hospital
- Brigham and Women’s Hospital, Channing Division of Network Medicine, Boston, Massachusetts
| | | | - Valerie A. Earnshaw
- Department of Human Development and Family Sciences, University of Delaware, Newark, Delaware, USA
| | - Ingrid Courtney
- Desmond Tutu HIV Foundation, University of Cape Town Medical School, Cape Town, South Africa
| | - Gugu Tshabalala
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Garrett M. Fitzmaurice
- Department of Medicine, Brigham and Women’s Hospital
- Harvard Medical School
- Department of Biostatistics, Harvard School of Public Health, Boston
- Laboratory for Psychiatric Biostatistics, McLean Hospital, Belmont, Massachusetts, USA
| | - Catherine Orrell
- Desmond Tutu HIV Foundation, University of Cape Town Medical School, Cape Town, South Africa
| | - Glenda Gray
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Office of the President, South African Medical Research Council, Western Cape, South Africa
| | - David R. Bangsberg
- Oregon Health & Science University-Portland State University School of Public Health, Portland, Oregon, USA
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19
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Tadege M. Predictors associated with HIV/AIDS patients dropout from antiretroviral therapy at Mettu Karl Hospital, southwest Ethiopia. BMC Res Notes 2019; 12:232. [PMID: 30999924 PMCID: PMC6471805 DOI: 10.1186/s13104-019-4267-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 04/12/2019] [Indexed: 01/16/2023] Open
Abstract
OBJECTIVE The aim of this study was to determine the major risk factors of antiretroviral therapy dropout. The retrospective cohort research design was applied. 1512 HIV patients were included from Mettu Karl Hospital in Illubabor Zone, southwest part of Ethiopia from September 2005 to January 2018. Kaplan-Meier comparison and log-logistic regression accelerated failure time model were used. RESULTS From the log-logistic regression result, the risk of dropout for patients with primary education status was 10.58% greater as compared to illiterate (p < 0.0110). The probability of dropout for patients with marital status separated was about 16.82% higher than those patients with marital status divorced (p < 0.0070). Being merchant, farmer and daily labour had a greater risk of dropout as compared to a housewife. Most of the HIV/AIDS patients on ART were dropout in a short period due to patients separated marital status, primary education, CD4, being merchants, farmer and daily labour. Investigation on the cause of antiretroviral therapy dropout from a number of AIDS clinics in the country is highly appreciated.
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Affiliation(s)
- Melaku Tadege
- Department of Statistics, Injibara University, Injibara, Amhara, Ethiopia.
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20
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Horwood C, Jama NA, Haskins L, Coutsoudis A, Spies L. A qualitative study exploring infant feeding decision-making between birth and 6 months among HIV-positive mothers. MATERNAL AND CHILD NUTRITION 2018; 15:e12726. [PMID: 30338632 DOI: 10.1111/mcn.12726] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 09/28/2018] [Accepted: 10/02/2018] [Indexed: 01/10/2023]
Abstract
Despite efforts to support breastfeeding for HIV-positive mothers in South Africa, being HIV-positive remains a barrier to initiating and sustaining breastfeeding. The aim was to explore decision-making about infant feeding practices among HIV-positive mothers in a rural and urban settings in KwaZulu-Natal, South Africa. HIV-positive pregnant women were purposively sampled from one antenatal clinic in each setting. A qualitative longitudinal cohort design was employed, with monthly in-depth interviews conducted over 6 months postdelivery. Data were analysed using framework analysis. We report findings from 11 HIV-positive women within a larger cohort. Participants were aged between 15 and 41 years and were all on antiretroviral therapy. Before delivery, nine mothers intended to exclusively breastfeed (EBF) for 6 months, and two intended to exclusively formula feed (EFF). Three mothers successfully EBF for 6 months, whereas four had stopped breastfeeding, and two were mixed breastfeeding by 6 months. Mothers reported receiving strong advice from health workers (HWs) to EBF and made decisions based primarily on HWs advice, resisting contrary pressure from family or friends. The main motivation for EBF was to protect the child from HIV acquisition, but sometimes fear of mixed feeding led to mothers stopping breastfeeding entirely. Infant feeding messages from HWs advice were frequently inadequate and out of date, and failed to address mothers' challenges. Minimal support was provided for EFF. In conclusion, HWs play a pivotal role in providing infant feeding support to HIV infected mothers, but need regular updates to ensure if advice is correct and appropriate.
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Affiliation(s)
- Christiane Horwood
- Centre for Rural Health, University of KwaZulu-Natal, Durban, South Africa
| | | | - Lyn Haskins
- Centre for Rural Health, University of KwaZulu-Natal, Durban, South Africa
| | - Anna Coutsoudis
- Department of Paediatrics and Child Health School of Clinical Medicine Nelson R Mandela School of Medicine, University of KwaZulu-Natal Durban, Durban, South Africa
| | - Lenore Spies
- Department of Health, Nutrition Directorate, Pietermaritzburg, South Africa
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21
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Fox MP, Pascoe SJS, Huber AN, Murphy J, Phokojoe M, Gorgens M, Rosen S, Wilson D, Pillay Y, Fraser-Hurt N. Effectiveness of interventions for unstable patients on antiretroviral therapy in South Africa: results of a cluster-randomised evaluation. Trop Med Int Health 2018; 23:1314-1325. [PMID: 30281882 DOI: 10.1111/tmi.13152] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND As loss from HIV care is an ongoing challenge globally, interventions are needed for patients who don't achieve or maintain ART stability. The 2015 South African National Adherence Guidelines (AGL) for Chronic Diseases include two interventions targeted at unstable patients: early tracing of patients who miss visits (TRIC) and enhanced adherence counselling (EAC). METHODS As part of a cluster-randomised evaluation at 12 intervention and 12 control clinics in four provinces, intervention sites implemented the AGL interventions, while control sites retained standard care. We report on outcomes of EAC for patients with an elevated viral load (>400 copies/ml) and for TRIC patients who missed a visit by >5 days. We estimated risk differences (RD) of 3 and 12-month viral resuppression (<400 copies/ml) and 12-month retention with cluster adjustment using generalised estimating equations and controlled for imbalances using difference-in-differences compared to all eligible in 2015, prior to intervention roll-out. RESULTS For EAC, we had 358 intervention and 505 control site patients (61% female, median ART initiation CD4 count 154 cells/μl). We found no difference between arms in 3-month resuppression (RD: -1.7%; 95%CI: -4.3% to 0.9%), but <20% of patients had a repeat viral load within 3 months (19.8% intervention, 13.5% control). Including the entire clinic population eligible for EAC with a repeat viral load at all evaluation sites (n = 934), intervention sites showed a small increase in 3-month resuppression (28% vs. 25%, RD 3.0%; 95%CI: -2.7% to 8.8%). Adjusting for baseline differences increased the RD to 8.1% (95% CI: -0.1% to 17.2%). However, we found no differences in 12-month suppression (RD: 1.5%; 95% CI: -14.1% to 17.1% but suppression was low overall at 40%) or retention (RD: 2.8%; 95% CI: -7.5% to 13.2%). For TRIC, we enrolled 155 at intervention sites and 248 at control sites (44% >40 years, 67% female, median CD4 count 212 cells/μl). We found no difference between groups in return to care by 12 months (RD: -6.8%; 95% CI: -17.7% to 4.8%). During the study period, control sites continued to use tracing within standard care, however, potentially masking intervention effects. CONCLUSIONS Enhanced adherence counselling showed no benefit over 12 months. Implementation of the tracing intervention under the new guidelines was similar to the standard of care. Interventions that aim to return unstable patients to care should incorporate active monitoring to determine if the interventions are effective.
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Affiliation(s)
- Matthew P Fox
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA.,Health Economics and Epidemiology Research Office, Department of Internal Medicine, Faculty of Health Sciences, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa.,Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Sophie J S Pascoe
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, Faculty of Health Sciences, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Amy N Huber
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, Faculty of Health Sciences, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Joshua Murphy
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, Faculty of Health Sciences, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | | | | | - Sydney Rosen
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA.,Health Economics and Epidemiology Research Office, Department of Internal Medicine, Faculty of Health Sciences, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Yogan Pillay
- National Department of Health, Pretoria, South Africa
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22
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Hendrickson CJ, Pascoe SJS, Huber AN, Moolla A, Maskew M, Long LC, Fox MP. "My future is bright…I won't die with the cause of AIDS": ten-year patient ART outcomes and experiences in South Africa. J Int AIDS Soc 2018; 21:e25184. [PMID: 30318848 PMCID: PMC6186968 DOI: 10.1002/jia2.25184] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 08/13/2018] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION South Africa is moving into a new era of HIV treatment with "treat all" policies where people may be on treatment for most of their lives. We need to understand treatment outcomes and facilitators of long-term antiretroviral treatment (ART) adherence and retention-in-care in the South African context. In one of the first studies to investigate long-term treatment outcomes in South Africa, we aimed to describe ten-year patient outcomes at a large public-sector HIV clinic in Johannesburg and explore patient experiences of the treatment programme over this time in order to ascertain factors that may aid or hinder long-term adherence and retention. METHODS We conducted a cohort analysis (n = 6644) and in-depth interviews (n = 24) among HIV-positive adults initiating first-line ART between April 2004 and March 2007. Using clinical records, we ascertained twelve-month and ten-year all-cause mortality and loss to follow-up (LTF). Cox proportional hazards regression was used to identify baseline predictors of attrition (mortality and LTF (>3 months late for the last scheduled visit)) at twelve months and ten years. Twenty-four patients were purposively selected and interviewed to explore treatment programme experiences over ten years on ART. RESULTS Excluding transfers, 79.5% (95% confidence intervals (CI): 78.5 to 80.5) of the cohort were alive, in care at twelve months dropping to 35.1% (95% CI: 33.7 to 36.4) at ten years. Over 44% of deaths occurred within 12 months. Ten-year all-cause mortality increased, while LTF decreased slightly, with age. Year and age at ART initiation, sex, nationality, baseline CD4 count, anaemia, body mass index and initiating regimen were predictors of ten-year attrition. Among patients interviewed, the pretreatment clinic environment, feelings of gratitude and good fortune, support networks, and self-efficacy were facilitators of care; side effects, travel and worsening clinical conditions were barriers. Participants were generally optimistic about their futures and were committed to continued care. CONCLUSIONS This study demonstrates the complexities of long-term chronic HIV treatment with declining all-cause mortality and increasing LTF over ten years. Barriers to long-term retention still present a significant challenge. As more people become eligible for ART in South Africa under "treatment for all," new healthcare delivery challenges will arise; interventions are needed to ensure long-term programme successes continue.
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Affiliation(s)
- Cheryl J Hendrickson
- Department of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesHealth Economics and Epidemiology Research OfficeUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Sophie J S Pascoe
- Department of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesHealth Economics and Epidemiology Research OfficeUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Amy N Huber
- Department of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesHealth Economics and Epidemiology Research OfficeUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Aneesa Moolla
- Department of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesHealth Economics and Epidemiology Research OfficeUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Mhairi Maskew
- Department of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesHealth Economics and Epidemiology Research OfficeUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Lawrence C Long
- Department of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesHealth Economics and Epidemiology Research OfficeUniversity of the WitwatersrandJohannesburgSouth Africa
- Department of Global HealthBoston University School of Public HealthBostonMAUSA
| | - Matthew P Fox
- Department of Internal MedicineSchool of Clinical MedicineFaculty of Health SciencesHealth Economics and Epidemiology Research OfficeUniversity of the WitwatersrandJohannesburgSouth Africa
- Department of Global HealthBoston University School of Public HealthBostonMAUSA
- Department of EpidemiologyBoston University School of Public HealthBostonMAUSA
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23
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Guiteau Moise C, Rivera VR, Hennessey KA, Bellot C, Nicholas C, Fang AP, Verdier RI, Severe P, Sainvil A, Charles B, Dorval D, St Amour J, Pape JW, Koenig SP. A Successful Model of Expedited Antiretroviral Therapy for Clinically Stable Patients Living With HIV in Haiti. J Acquir Immune Defic Syndr 2018; 79:70-76. [PMID: 29771791 PMCID: PMC6092230 DOI: 10.1097/qai.0000000000001725] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Recommendations for universal antiretroviral therapy have greatly increased the number of HIV-infected patients who qualify for treatment, particularly with early clinical disease. Less intensive models of care are needed for clinically stable patients. SETTING A rapid pathway (RP) model of expedited outpatient care for clinically stable patients was implemented at the Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO) Center, Port-au-Prince, Haiti. Expedited visits included nurse-led assessments and point-of-service antiretroviral therapy dispensing. METHODS We conducted a retrospective analysis including patients who initiated RP care between June 1, 2014, and September 30, 2015, comparing outcomes of patients with timely visit attendance (never >3 days late) with patients with ≥1 nontimely visit within 6 months before RP enrollment. We calculated retention in care and adherence at 12 months, and assessed predictors of both outcomes. RESULTS Of the 2361 patients who initiated RP care during the study period, 1429 (61%) had timely visit attendance and 932 (39%) had ≥1 nontimely visit before RP enrollment. Among RP-enrolled patients, 94% were retained at 12 months and 75% had ≥90% adherence, with higher proportions in those with timely pre-RP visits (95% vs. 92%; 87% vs. 55%). In multivariable analysis, pre-RP visit timeliness was associated with both retention (adjusted odds ratio: 1.67; 95% confidence interval: 1.08 to 2.59) and adherence (adjusted odds ratio: 4.53; 95% confidence interval: 3.58 to 5.72). CONCLUSIONS RP care was associated with high levels of retention and adherence for clinically stable patients. Timeliness of pre-RP visits was predictive of outcomes after RP initiation.
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Affiliation(s)
- Colette Guiteau Moise
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Vanessa R Rivera
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
- Division of Global Health, Weill Cornell Medical College, New York, NY
| | - Kelly A Hennessey
- Analysis Group, Boston, MA
- University of Washington School of Medicine, Seattle, WA
| | - Clovy Bellot
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Chris Nicholas
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Anna P Fang
- Analysis Group, Boston, MA
- Harvard Medical School, Boston, MA
| | - Rose Irène Verdier
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Patrice Severe
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Alix Sainvil
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Benedict Charles
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Derothy Dorval
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Juseline St Amour
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Jean W Pape
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
- Division of Global Health, Weill Cornell Medical College, New York, NY
| | - Serena P Koenig
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA
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24
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Ahmed S, Autrey J, Katz IT, Fox MP, Rosen S, Onoya D, Bärnighausen T, Mayer KH, Bor J. Why do people living with HIV not initiate treatment? A systematic review of qualitative evidence from low- and middle-income countries. Soc Sci Med 2018; 213:72-84. [PMID: 30059900 PMCID: PMC6813776 DOI: 10.1016/j.socscimed.2018.05.048] [Citation(s) in RCA: 69] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Revised: 05/15/2018] [Accepted: 05/25/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Many people living with HIV (PLWH) who are eligible for antiretroviral therapy (ART) do not initiate treatment, leading to excess morbidity, mortality, and viral transmission. As countries move to treat all PLWH at diagnosis, it is critical to understand reasons for non-initiation. METHODS We conducted a systematic review of the qualitative literature on reasons for ART non-initiation in low- and middle-income countries. We screened 1376 titles, 680 abstracts, and 154 full-text reports of English-language qualitative studies published January 2000-April 2017; 20 met criteria for inclusion. Our analysis involved three steps. First, we used a "thematic synthesis" approach, identifying supply-side (facility) and demand-side (patient) factors commonly cited across different studies and organizing these factors into themes. Second, we conducted a theoretical mapping exercise, developing an explanatory model for patients' decision-making process to start (or not to start) ART, based on inductive analysis of evidence reviewed. Third, we used this explanatory model to identify opportunities to intervene to increase ART uptake. RESULTS Demand-side factors implicated in decisions not to start ART included feeling healthy, low social support, gender norms, HIV stigma, and difficulties translating intentions into actions. Supply-side factors included high care-seeking costs, concerns about confidentiality, low-quality health services, recommended lifestyle changes, and incomplete knowledge of treatment benefits. Developing an explanatory model, which we labeled the Transdisciplinary Model of Health Decision-Making, we posited that contextual factors determine the costs and benefits of ART; patients perceive this context (through cognitive and emotional appraisals) and form an intention whether or not to start; and these intentions may (or may not) be translated into actions. Interventions can target each of these three stages. CONCLUSIONS Reasons for not starting ART included consistent themes across studies. Future interventions could: (1) provide information on the large health and prevention benefits of ART and the low side effects of current regimens; (2) reduce stigma at the patient and community levels and increase confidentiality where stigma persists; (3) remove lifestyle requirements and support patients in integrating ART into their lives; and (4) alleviate economic burdens of ART. Interventions addressing reasons for non-initiation will be critical to the success of HIV "treat all" strategies.
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Affiliation(s)
- Shahira Ahmed
- Department of Global Health, Boston University School of Public Health, Boston, United States
| | - Jessica Autrey
- Department of Global Health, Boston University School of Public Health, Boston, United States
| | - Ingrid T Katz
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States; Massachusetts General Hospital, Center for Global Health, Boston, MA, United States
| | - Matthew P Fox
- Department of Global Health, Boston University School of Public Health, Boston, United States; Department of Epidemiology, Boston University School of Public Health, Boston, United States; Health Economics and Epidemiology Research Office, Wits Health Consortium, Faculty of Medical Sciences, University of the Witwatersrand Medical School, Johannesburg, South Africa
| | - Sydney Rosen
- Department of Global Health, Boston University School of Public Health, Boston, United States; Health Economics and Epidemiology Research Office, Wits Health Consortium, Faculty of Medical Sciences, University of the Witwatersrand Medical School, Johannesburg, South Africa
| | - Dorina Onoya
- Health Economics and Epidemiology Research Office, Wits Health Consortium, Faculty of Medical Sciences, University of the Witwatersrand Medical School, Johannesburg, South Africa
| | - Till Bärnighausen
- Heidelberg Institute of Public Health, University of Heidelberg, Heidelberg, Germany; Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, United States; Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - Kenneth H Mayer
- Harvard Medical School, Boston, MA, United States; The Fenway Institute, Boston, United States
| | - Jacob Bor
- Department of Global Health, Boston University School of Public Health, Boston, United States; Department of Epidemiology, Boston University School of Public Health, Boston, United States; Health Economics and Epidemiology Research Office, Wits Health Consortium, Faculty of Medical Sciences, University of the Witwatersrand Medical School, Johannesburg, South Africa; Africa Health Research Institute, KwaZulu-Natal, South Africa.
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25
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Kelly JD, Hickey MD, Schlough GW, Conteh S, Sesay M, Rutherford GW, Giordano TP, Weiser SD. Understanding why HIV-infected persons disengaged from pre-ART care in Freetown, Sierra Leone: a qualitative study .. AIDS Care 2018; 31:494-497. [PMID: 30146898 DOI: 10.1080/09540121.2018.1515467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
In countries that have not implemented universal antiretroviral treatment (ART), loss to follow-up (LTFU) during pre-ART care remains a problem. We conducted semi-structured interviews with 41 HIV-infected persons who were LTFU during pre-ART care from a prospective cohort of persons newly diagnosed with HIV infection in Freetown, Sierra Leone, in 2012-2013. Interviews determined whether the participant disengaged or transferred care and explored the reasons for being LTFU. Of the 41 participants, 34 (83%) disengaged from care. For persons who disengaged from care, socioeconomic barriers emerged as a dominant theme in both ART-eligible and -ineligible groups while psychosocial barriers emerged as a dominant theme in the ART-ineligible group. Structural barriers emerged as a dominant theme for participants who transferred care. Interventions designed to address socioeconomic and psychosocial barriers may help reduce disengagement from pre-ART care.
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Affiliation(s)
- J Daniel Kelly
- a Department of Epidemiology and Biostatistics , University of California , San Francisco , CA , USA.,b Wellbody Alliance , Koidu Town , Sierra Leone.,c National HIV/AIDS Secretariat , Freetown , Sierra Leone
| | - Matthew D Hickey
- a Department of Epidemiology and Biostatistics , University of California , San Francisco , CA , USA
| | | | - Sulaiman Conteh
- c National HIV/AIDS Secretariat , Freetown , Sierra Leone.,d College of Medicine and Allied Health Sciences of University of Sierra Leone , Freetown , Sierra Leone
| | - Momodu Sesay
- c National HIV/AIDS Secretariat , Freetown , Sierra Leone
| | - George W Rutherford
- a Department of Epidemiology and Biostatistics , University of California , San Francisco , CA , USA
| | - Thomas P Giordano
- e Department of Medicine , Baylor College of Medicine , Houston , TX , USA
| | - Sheri D Weiser
- a Department of Epidemiology and Biostatistics , University of California , San Francisco , CA , USA
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26
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Larson BA, Bii M, Halim N, Rohr JK, Sugut W, Sawe F. Incremental treatment costs for HIV-infected women initiating antiretroviral therapy during pregnancy: A 24-month micro-costing cohort study for a maternal and child health clinic in Kenya. PLoS One 2018; 13:e0200199. [PMID: 30096177 PMCID: PMC6086393 DOI: 10.1371/journal.pone.0200199] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Accepted: 06/21/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND To date, little information exists on the costs of providing antiretroviral therapy (ART) within maternal and child health (MCH) clinics in Kenya. The main objective of this analysis was to estimate the annual incremental cost of providing ART within a MCH clinic for adult women initiated on ART during pregnancy over the first one and two years on treatment. The study site was the District Hospital in Kericho, Kenya. METHODS A micro-costing approach from the provider's perspective, based on a retrospective review of patient medical records, was used to evaluate incremental costs of care (2012 USD). Cost per patient in two cohorts were evaluated: the MCH clinic group comprised of adult women who initiated ART at the site's MCH clinic during pregnancy between 2008-2011; and for comparison, the ART clinic group comprised of adult, non-pregnant women who initiated ART at the site's ART clinic during 2008-2011. The two groups were matched on age and baseline CD4 count at initiation. Retention at year one/two on ART was defined as having completed a clinic visit at 365/730 days on ART +/- 90 days. RESULTS For patients defined as retained in care at year one, average incremental costs per patient were $234 for the MCH clinic group (median: 215; IQR: 186, 282) and $292 in the ART clinic group (median: 227; IQR: 178, 357). ARV and laboratory costs were less on average for the MCH clinic group compared to the ART clinic group (due to lower cost regimens and fewer tests), while personnel costs were higher for the MCH clinic group. CONCLUSIONS The annual incremental cost per patient of providing ART were similar in the two clinic settings in 2012. With shifts in recommended ARV regimens and lab monitoring over time, annual costs of care (using 2016 USD unit costs) have remained relatively constant in nominal terms for the MCH clinic group but have fallen substantially for the ART clinic group (from nominal $292 in 2012 to nominal $227 in 2016).
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Affiliation(s)
- Bruce A. Larson
- Department of Global Health, Boston University School of Public Health, Boston, MA, United States of America
- * E-mail:
| | - Margaret Bii
- Kenya Medical Research Institute/Walter Reed Project, Kericho, Kenya
- HJF Medical Research International, Inc., Nairobi, Kenya
| | - Nafisa Halim
- Department of Global Health, Boston University School of Public Health, Boston, MA, United States of America
| | - Julia K. Rohr
- Harvard Center for Population and Development Studies, Cambridge, MA, United States of America
| | - William Sugut
- Kenya Medical Research Institute/Walter Reed Project, Kericho, Kenya
- HJF Medical Research International, Inc., Nairobi, Kenya
| | - Fredrick Sawe
- Kenya Medical Research Institute/Walter Reed Project, Kericho, Kenya
- HJF Medical Research International, Inc., Nairobi, Kenya
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Dareng EO, Olaniyan Y, Adebamowo SN, Eseyin OR, Odutola MK, Obiefuna EM, Offiong RA, Pharoah PP, Adebamowo CA. Age, HIV status, and research context determined attrition in a longitudinal cohort in Nigeria. J Clin Epidemiol 2018; 100:32-43. [PMID: 29679747 PMCID: PMC8015251 DOI: 10.1016/j.jclinepi.2018.04.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 04/03/2018] [Accepted: 04/11/2018] [Indexed: 01/12/2023]
Abstract
OBJECTIVES We explored determinants of attrition in a longitudinal cohort study in Nigeria. STUDY DESIGN AND SETTING We enrolled 1,020 women into a prospective study. Of these, 973 were eligible to return for follow-up. We investigated the determinants of attrition among eligible women using a sequential mixed methods design. We used logistic regression models to compare the baseline characteristics of responders and nonresponders. At the end of the parent study, we conducted four focus group discussions and eight key informant interviews with nonresponders. RESULTS Of the 973 women included in the quantitative analysis, 26% were nonresponders. From quantitative analysis, older women were less likely to drop out than younger women (reference: women ≤30 years; OR 0.46; 95% confidence interval [CI] 0.30-0.70, P < 0.001 women 31-44 years; and OR 0.31; 95% CI 0.17-0.56, P < 0.001 women ≥45 years). HIV-positive women were also less likely to drop out of the study (OR 0.45; 95% CI 0.33-0.63, P < 0.001). From qualitative analysis, contextual factors that influenced attrition were high cost of participation, therapeutic misconceptions, inaccurate expectations, spousal disapproval, unpleasant side effects, challenges in maintaining contact with participants, and participant difficulties in locating the study clinic. CONCLUSION Several participant-, research-, and environment-related factors influence attrition. Retention strategies that address these barriers are important to minimize attrition.
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Affiliation(s)
- Eileen O Dareng
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom; Office of Strategic Information, Research and Training, Institute of Human Virology, Abuja, Nigeria
| | - Yinka Olaniyan
- Department of Obstetrics and Gynecology, National Hospital, Abuja, Nigeria
| | - Sally N Adebamowo
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA; Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA; Marlene and Stewart Greenbaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Olabimpe R Eseyin
- Office of Strategic Information, Research and Training, Institute of Human Virology, Abuja, Nigeria
| | - Michael K Odutola
- Office of Strategic Information, Research and Training, Institute of Human Virology, Abuja, Nigeria
| | - Elonna M Obiefuna
- Office of Strategic Information, Research and Training, Institute of Human Virology, Abuja, Nigeria
| | - Richard A Offiong
- Department of Obstetrics and Gynecology, University of Abuja Teaching Hospital, Abuja, Nigeria
| | - Paul P Pharoah
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - Clement A Adebamowo
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA; Marlene and Stewart Greenbaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, MD, USA; Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA.
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Lambert RF, Orrell C, Bangsberg DR, Haberer JE. Factors that Motivated Otherwise Healthy HIV-Positive Young Adults to Access HIV Testing and Treatment in South Africa. AIDS Behav 2018; 22:733-741. [PMID: 28190116 DOI: 10.1007/s10461-017-1704-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The World Health Organization recommends early initiation of HIV antiretroviral therapy (ART) for all those infected with the virus at any CD4 count. Successfully reaching individuals with relatively high CD4 counts depends in large part on healthy individuals seeking testing and treatment; however, little is known about factors motivating this decision. We conducted a qualitative study to explore this issue among 25 young HIV-positive adults (age 18-35) with a CD4 count >350 cells/mm3 who recently started or made the decision to start ART in Gugulethu, South Africa. Using an inductive content analytical approach, we found that most individuals sought testing and treatment early in the disease progression because of a desire to appear healthy thereby avoiding stigma associated with AIDS. Other factors included social support, responsibilities and aspirations, normalcy of having HIV, and accessible services. These findings suggest that maintenance of physical appearance should be included in the development of novel testing and treatment interventions.
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Affiliation(s)
| | - Catherine Orrell
- Desmond Tutu HIV Foundation, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - David R Bangsberg
- Center for Global Health, Massachusetts General Hospital, 125 Nashua St, Suite 722, Boston, MA, 02114, USA
- Harvard Medical School, Harvard University, Boston, MA, USA
| | - Jessica E Haberer
- Center for Global Health, Massachusetts General Hospital, 125 Nashua St, Suite 722, Boston, MA, 02114, USA.
- Harvard Medical School, Harvard University, Boston, MA, USA.
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Naik R, Zembe W, Adigun F, Jackson E, Tabana H, Jackson D, Feeley F, Doherty T. What Influences Linkage to Care After Home-Based HIV Counseling and Testing? AIDS Behav 2018. [PMID: 28643242 PMCID: PMC5847222 DOI: 10.1007/s10461-017-1830-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
To maximize the benefits of test and treat strategies that utilize community-based HIV testing, clients who test positive must link to care in a timely manner. However, linkage rates across the HIV treatment cascade are typically low and little is known about what might facilitate or hinder care-seeking behavior. This qualitative study was conducted within a home-based HIV counseling and testing (HBHCT) intervention in South Africa. In-depth interviews were conducted with 30 HBHCT clients who tested HIV positive to explore what influenced their care-seeking behavior. A set of field notes for 196 additional HBHCT clients who tested HIV positive at home were also reviewed and analyzed. Content analysis showed that linkage to care is influenced by a myriad of factors at the individual, relationship, community, and health system levels. These factors subtly interact and at times reinforce each other. While some factors such as belief in test results, coping ability, social support, and prior experiences with the health system affect clients’ desire and motivation to seek care, others such as limited time and resources affect their agency to do so. To ensure that the benefits of community-based testing models are realized through timely linkage to care, programs and interventions must take into account and address clients’ emotions, motivation levels, living situations, relationship dynamics, responsibilities, and personal resources.
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Affiliation(s)
- Reshma Naik
- Health Systems Research Unit, South African Medical Research Council, Tygerberg, South Africa.
- Department of Global Health, School of Public Health, Boston University, Boston, MA, USA.
- Population Reference Bureau, 1875 Connecticut Avenue, NW, Suite 520, Washington, DC, USA.
| | - Wanga Zembe
- Health Systems Research Unit, South African Medical Research Council, Tygerberg, South Africa
| | - Fatima Adigun
- Department of Global Health, School of Public Health, Boston University, Boston, MA, USA
| | - Elizabeth Jackson
- Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York City, NY, USA
| | - Hanani Tabana
- Department of Public Health Sciences, Karolinska Institute, Stockholm, Sweden
| | - Debra Jackson
- School of Public Health, University of the Western Cape, Bellville, South Africa
| | - Frank Feeley
- Department of Global Health, School of Public Health, Boston University, Boston, MA, USA
| | - Tanya Doherty
- Health Systems Research Unit, South African Medical Research Council, Tygerberg, South Africa
- School of Public Health, University of the Western Cape, Bellville, South Africa
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Fox MP, Pascoe SJ, Huber AN, Murphy J, Phokojoe M, Gorgens M, Rosen S, Wilson D, Pillay Y, Fraser-Hurt N. Assessing the impact of the National Department of Health's National Adherence Guidelines for Chronic Diseases in South Africa using routinely collected data: a cluster-randomised evaluation. BMJ Open 2018; 8:e019680. [PMID: 29358446 PMCID: PMC5781226 DOI: 10.1136/bmjopen-2017-019680] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
INTRODUCTION In 2016, South Africa's National Department of Health (NDOH) launched the National Adherence Guidelines for Chronic Diseases for phased implementation throughout South Africa. Early implementation of a 'minimum package' of eight interventions in the Adherence Guidelines for patients with HIV is being undertaken at 12 primary health clinics and community health centres in four provinces. NDOH and its partners are evaluating the impact of five of the interventions in four provinces in South Africa. METHODS AND ANALYSIS The minimum package is being delivered at the 12 health facilities under NDOH guidance and through local health authorities. The five evaluation interventions are: (1) fast track initiation counselling for patients eligible for antiretroviral therapy (ART); (2) adherence clubs for stable ART patients; (3) decentralised medication delivery for stable ART patients; (4) enhanced adherence counselling for unstable ART patients; and (5) early tracing of patients who miss an appointment by ≥5 days. For evaluation, NDOH matched the 12 intervention clinics with 12 comparison clinics and randomly allocated one member of each pair to intervention or comparison (standard of care) status within pairs, allowing evaluation of the interventions using a matched cluster-randomised design. The evaluation uses data routinely collected by the clinics, with no study interaction with subjects to prevent influencing the primary outcomes. Enrolment began on 20 June 2016 and was completed on 16 December 2016. A total of 3456 patients were enrolled and will now be followed for 14 months to estimate effects on short-term and final outcomes. Primary outcomes include viral suppression, retention and medication pickups, evaluated at two time points during follow-up. ETHICS AND DISSEMINATION The study received approval from the University of Witwatersrand Human Research Ethics Committee and Boston University Institutional Review Board. Results will be presented to key stakeholders and at international conferences and published in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT02536768; Pre-results.
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Affiliation(s)
- Matthew P Fox
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Sophie J Pascoe
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Amy N Huber
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Joshua Murphy
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | | | - Sydney Rosen
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Yogan Pillay
- National Department of Health, Pretoria, South Africa
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Sabapathy K, Mubekapi‐Musadaidzwa C, Mulubwa C, Schaap A, Hoddinott G, Stangl A, Floyd S, Ayles H, Fidler S, Hayes R. Predictors of timely linkage-to-ART within universal test and treat in the HPTN 071 (PopART) trial in Zambia and South Africa: findings from a nested case-control study. J Int AIDS Soc 2017; 20:e25037. [PMID: 29251433 PMCID: PMC5810326 DOI: 10.1002/jia2.25037] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Accepted: 11/27/2017] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION HPTN 071 (PopART) is a three-arm community randomized trial in Zambia and South Africa evaluating the impact of a combination HIV prevention package, including universal test and treat (UTT), on HIV incidence. This nested study examined factors associated with timely linkage-to-care and ART initiation (TLA) (i.e. within six-months of referral) in the context of UTT within the intervention communities of the HPTN 071 (PopART) trial. METHODS Of the 7572 individuals identified as persons living with HIV (PLWH) (and not on antiretroviral treatment (ART)) during the first year of the PopART intervention provided by Community HIV-care Providers (CHiPs) through door-to-door household visits, individuals who achieved TLA (controls) and those who did not (cases), stratified by gender and community, were randomly selected to be re-contacted for interview. Standardized questionnaires were administered to explore factors potentially associated with TLA, including demographic and behavioural characteristics, and participants' opinions on HIV and related services. Odds ratios comparing cases and controls were estimated using a multi-variable logistic regression. RESULTS Data from 705 participants (333 cases/372 controls) were analysed. There were negligible differences between cases and controls by demographic characteristics including age, marital or socio-economic position. Prior familiarity with the CHiPs encouraged TLA (aOR of being a case: 0.58, 95% CI: 0.39 to 0.86, p = 0.006). Participants who found clinics overcrowded (aOR: 1.51, 95% CI: 1.08 to 2.12, p = 0.006) or opening hours inconvenient (aOR: 1.63, 95% CI: 1.06 to 2.51, p = 0.02) were less likely to achieve TLA, as were those expressing stronger feelings of shame about having HIV (ptrend = 0.007). Expressing "not feeling ready" (aOR: 2.75, 95% CI: 1.89 to 4.01, p < 0.001) and preferring to wait until they felt sick (aOR: 2.00, 95% CI: 1.27 to 3.14, p = 0.02) were similarly indicative of being a case. Worrying about being seen in the clinic or about how staff treated patients was not associated with TLA. While the association was not strong, we found that the greater the number of self-reported lifetime sexual partners the more likely participants were to achieve TLA (ptrend = 0.06). There was some evidence that participants with HIV-positive partners on ART were less likely to be cases (aOR: 0.75, 95% CI: 0.53 to 1.06, p = 0.07). DISCUSSION The lack of socio-demographic differences between cases and controls is encouraging for a "universal" intervention that seeks to ensure high coverage across whole communities. Making clinics more "patient-friendly" could enhance treatment uptake further. The finding that those with higher risk behaviour are more actively engaging with UTT holds promise for treatment-as-prevention.
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Affiliation(s)
| | | | - Chama Mulubwa
- Desmond Tutu TB CentreDepartment of Paediatrics and Child HealthFaculty of Medicine and Health SciencesStellenbosch UniversityCape TownSouth Africa
| | - Ab Schaap
- Desmond Tutu TB CentreDepartment of Paediatrics and Child HealthFaculty of Medicine and Health SciencesStellenbosch UniversityCape TownSouth Africa
| | | | - Anne Stangl
- International Centre for Research on WomenWashingtonDCUSA
| | - Sian Floyd
- London School of Hygiene and Tropical MedicineLondonUnited Kingdom
| | - Helen Ayles
- London School of Hygiene and Tropical MedicineLondonUnited Kingdom
- Desmond Tutu TB CentreWestern CapeSouth Africa
| | | | - Richard Hayes
- London School of Hygiene and Tropical MedicineLondonUnited Kingdom
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McNairy ML, Lamb MR, Gachuhi AB, Nuwagaba-Biribonwoha H, Burke S, Mazibuko S, Okello V, Ehrenkranz P, Sahabo R, El-Sadr WM. Effectiveness of a combination strategy for linkage and retention in adult HIV care in Swaziland: The Link4Health cluster randomized trial. PLoS Med 2017; 14:e1002420. [PMID: 29112963 PMCID: PMC5675376 DOI: 10.1371/journal.pmed.1002420] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Accepted: 09/29/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Gaps in the HIV care continuum contribute to poor health outcomes and increase HIV transmission. A combination of interventions targeting multiple steps in the continuum is needed to achieve the full beneficial impact of HIV treatment. METHODS AND FINDINGS Link4Health, a cluster-randomized controlled trial, evaluated the effectiveness of a combination intervention strategy (CIS) versus the standard of care (SOC) on the primary outcome of linkage to care within 1 month plus retention in care at 12 months after HIV-positive testing. Ten clusters of HIV clinics in Swaziland were randomized 1:1 to CIS versus SOC. The CIS included point-of-care CD4+ testing at the time of an HIV-positive test, accelerated antiretroviral therapy (ART) initiation for treatment-eligible participants, mobile phone appointment reminders, health educational packages, and noncash financial incentives. Secondary outcomes included each component of the primary outcome, mean time to linkage, assessment for ART eligibility, ART initiation and time to ART initiation, viral suppression defined as HIV-1 RNA < 1,000 copies/mL at 12 months after HIV testing among patients on ART ≥6 months, and loss to follow-up and death at 12 months after HIV testing. A total of 2,197 adults aged ≥18 years, newly tested HIV positive, were enrolled from 19 August 2013 to 21 November 2014 (1,096 CIS arm; 1,101 SOC arm) and followed for 12 months. The median participant age was 31 years (IQR 26-39), and 59% were women. In an intention-to-treat analysis, 64% (705/1,096) of participants at the CIS sites achieved the primary outcome versus 43% (477/1,101) at the SOC sites (adjusted relative risk [RR] 1.52, 95% CI 1.19-1.96, p = 0.002). Participants in the CIS arm versus the SOC arm had the following secondary outcomes: linkage to care regardless of retention at 12 months (RR 1.08, 95% CI 0.97-1.21, p = 0.13), mean time to linkage (2.5 days versus 7.5 days, p = 0.189), retention in care at 12 months regardless of time to linkage (RR 1.48, 95% CI 1.18-1.86, p = 0.002), assessment for ART eligibility (RR 1.20, 95% CI 1.07-1.34, p = 0.004), ART initiation (RR 1.16, 95% CI 0.96-1.40, p = 0.12), mean time to ART initiation from time of HIV testing (7 days versus 14 days, p < 0.001), viral suppression among those on ART for ≥6 months (RR 0.97, 95% CI 0.88-1.07, p = 0.55), loss to follow-up at 12 months after HIV testing (RR 0.56, 95% CI 0.40-0.79, p = 0.002), and death (N = 78) within 12 months of HIV testing (RR 0.80, 95% CI 0.46-1.35, p = 0.41). Limitations of this study include a small number of clusters and the inability to evaluate the incremental effectiveness of individual components of the combination strategy. CONCLUSIONS A combination strategy inclusive of 5 evidence-based interventions aimed at multiple steps in the HIV care continuum was associated with significant increase in linkage to care plus 12-month retention. This strategy offers promise of enhanced outcomes for HIV-positive patients. TRIAL REGISTRATION ClinicalTrials.gov NCT01904994.
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Affiliation(s)
- Margaret L. McNairy
- ICAP at Columbia University, New York, New York, United States of America
- Department of Medicine, Weill Cornell Medical College, New York, New York, United States of America
- * E-mail:
| | - Matthew R. Lamb
- ICAP at Columbia University, New York, New York, United States of America
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, United States of America
| | - Averie B. Gachuhi
- ICAP at Columbia University, New York, New York, United States of America
| | - Harriet Nuwagaba-Biribonwoha
- ICAP at Columbia University, New York, New York, United States of America
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, United States of America
| | - Sean Burke
- ICAP at Columbia University, New York, New York, United States of America
| | | | - Velephi Okello
- Ministry of Health, Kingdom of Swaziland, Mbabane, Swaziland
| | - Peter Ehrenkranz
- Bill and Melinda Gates Foundation, Seattle, Washington, United States of America
| | - Ruben Sahabo
- ICAP at Columbia University, New York, New York, United States of America
| | - Wafaa M. El-Sadr
- ICAP at Columbia University, New York, New York, United States of America
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, United States of America
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Katz IT, Kaplan R, Fitzmaurice G, Leone D, Bangsberg DR, Bekker LG, Orrell C. Treatment guidelines and early loss from care for people living with HIV in Cape Town, South Africa: A retrospective cohort study. PLoS Med 2017; 14:e1002434. [PMID: 29136014 PMCID: PMC5685472 DOI: 10.1371/journal.pmed.1002434] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 10/10/2017] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND South Africa has undergone multiple expansions in antiretroviral therapy (ART) eligibility from an initial CD4+ threshold of ≤200 cells/μl to providing ART for all people living with HIV (PLWH) as of September 2016. We evaluated the association of programmatic changes in ART eligibility with loss from care, both prior to ART initiation and within the first 16 weeks of starting treatment, during a period of programmatic expansion to ART treatment at CD4+ ≤ 350 cells/μl. METHODS AND FINDINGS We performed a retrospective cohort study of 4,025 treatment-eligible, non-pregnant PLWH accessing care in a community health center in Gugulethu Township affiliated with the Desmond Tutu HIV Centre in Cape Town. The median age of participants was 34 years (IQR 28-41 years), almost 62% were female, and the median CD4+ count was 173 cells/μl (IQR 92-254 cells/μl). Participants were stratified into 2 cohorts: an early cohort, enrolled into care at the health center from 1 January 2009 to 31 August 2011, when guidelines mandated that ART initiation required CD4+ ≤ 200 cells/μl, pregnancy, advanced clinical symptoms (World Health Organization [WHO] stage 4), or comorbidity (active tuberculosis); and a later cohort, enrolled into care from 1 September 2011 to 31 December 2013, when the treatment threshold had been expanded to CD4+ ≤ 350 cells/μl. Demographic and clinical factors were compared before and after the policy change using chi-squared tests to identify potentially confounding covariates, and logistic regression models were used to estimate the risk of pre-treatment (pre-ART) loss from care and early loss within the first 16 weeks on treatment, adjusting for age, baseline CD4+, and WHO stage. Compared with participants in the later cohort, participants in the earlier cohort had significantly more advanced disease: median CD4+ 146 cells/μl versus 214 cells/μl (p < 0.001), 61.1% WHO stage 3/4 disease versus 42.8% (p < 0.001), and pre-ART mortality of 34.2% versus 16.7% (p < 0.001). In total, 385 ART-eligible PLWH (9.6%) failed to initiate ART, of whom 25.7% died before ever starting treatment. Of the 3,640 people who started treatment, 58 (1.6%) died within the first 16 weeks in care, and an additional 644 (17.7%) were lost from care within 16 weeks of starting ART. PLWH who did start treatment in the later cohort were significantly more likely to discontinue care in <16 weeks (19.8% versus 15.8%, p = 0.002). After controlling for baseline CD4+, WHO stage, and age, this effect remained significant (adjusted odds ratio [aOR] = 1.30, 95% CI 1.09-1.55). As such, it remains unclear if early attrition from care was due to a "healthy cohort" effect or to overcrowding as programs expanded to accommodate the broader guidelines for treatment. Our findings were limited by a lack of generalizability (given that these data were from a single high-volume site where testing and treatment were available) and an inability to formally investigate the effect of crowding on the main outcome. CONCLUSIONS Over one-quarter of this ART-eligible cohort did not achieve the long-term benefits of treatment due to early mortality, ART non-initiation, or early ART discontinuation. Those who started treatment in the later cohort appeared to be more likely to discontinue care early, and this outcome appeared to be independent of CD4+ count or WHO stage. Future interventions should focus on those most at risk for early loss from care as programs continue to expand in South Africa.
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Affiliation(s)
- Ingrid T. Katz
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
- Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
- * E-mail:
| | - Richard Kaplan
- Desmond Tutu HIV Centre, University of Cape Town Medical School, Cape Town, South Africa
| | - Garrett Fitzmaurice
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
- Laboratory for Psychiatric Biostatistics, McLean Hospital, Belmont, Massachusetts, United States of America
| | - Dominick Leone
- Ragon Institute of MGH, MIT and Harvard, Boston, Massachusetts, United States of America
| | - David R. Bangsberg
- Oregon Health & Science University–Portland State University School of Public Health, Portland, Oregon, United States of America
| | - Linda-Gail Bekker
- Desmond Tutu HIV Centre, University of Cape Town Medical School, Cape Town, South Africa
| | - Catherine Orrell
- Desmond Tutu HIV Centre, University of Cape Town Medical School, Cape Town, South Africa
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Agolory SG, Auld AF, Odafe S, Shiraishi RW, Dokubo EK, Swaminathan M, Dalhatu I, Onotu D, Abiri O, Debem H, Bashorun A, Ellerbrock TV. High rates of loss to follow-up during the first year of pre-antiretroviral therapy for HIV patients at sites providing pre-ART care in Nigeria, 2004-2012. PLoS One 2017; 12:e0183823. [PMID: 28863160 PMCID: PMC5581182 DOI: 10.1371/journal.pone.0183823] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Accepted: 08/11/2017] [Indexed: 12/27/2022] Open
Abstract
Background With about 3.4 million HIV-infected persons, Nigeria has the second highest number of people living with HIV (PLHIV) in the world. However, antiretroviral treatment (ART) coverage in Nigeria remains low with only 748,846 (22%) of PLHIV on ART by the end of 2014. Retention of HIV-infected patients in pre-ART care is essential to ensure timely ART initiation. We assessed outcomes of patients enrolled in Nigeria’s pre-ART program during 2004–2012. Methods We conducted a nationally representative retrospective cohort study among adults (≥15 years old), enrolling in pre-ART programs supported by the U.S. President’s Emergency Plan for AIDS Relief in Nigeria. A total of 35 sites enrolling ≥50 patients in pre-ART were selected using probability proportional-to-size sampling; 2,415 eligible medical records at these sites were randomly selected for abstraction. Determinants of loss to follow-up (LTFU) and mortality during pre-ART care were estimated using Cox proportional hazards regression models. Results The median age at enrollment was 32 years (interquartile range (IQR) 27–40). A total of 1,216 (51.4%) initiated ART by the time of data abstraction. Among the remaining 1,199 patients, 898 (74.9%) had been LTFU, 180 (15.0%) were alive and in pre-ART care, 71 (5.9%) had died, 50 (4.2%) had transferred out or stopped care. Baseline markers of advanced disease, including weight <45 kg (adjusted hazard ration (AHR) = 4.23; 95% confidence interval (CI): 1.51–15.58) and more advanced WHO disease stage, were predictive of pre-ART mortality. Compared with patients aged 15–24, patients aged 35–44 (AHR = 0.67; 95% CI: 1.0.47–0.95) and age 45–54 (AHR = 0.66; 95% CI: 0.48–0.91) had lower LTFU rates. Compared with attending facilities in North Central geopolitical zone, attending facility locations in South East (AHR = 0.44; 95% CI: 0.24–0.83) was protective against LTFU. Conclusions About half of patients enrolling in HIV program during 2004–2012 in Nigeria had not initiated ART by 2013. Key strategies to improve early ART initiation among pre-ART enrollees include implementation of the WHO test and treat guidelines, earlier HIV testing, and better monitoring to improve ART initiation rates. Further research to understand regional variations in pre-ART outcomes is warranted.
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Affiliation(s)
- Simon G. Agolory
- Division of Global HIV & TB, U.S. Centers for Disease Control & Prevention, Atlanta, United States of America
| | - Andrew F. Auld
- Division of Global HIV & TB, U.S. Centers for Disease Control & Prevention, Atlanta, United States of America
| | - Solomon Odafe
- Division of Global HIV & TB, U.S. Centers for Disease Control & Prevention, Abuja, Nigeria
- * E-mail:
| | - Ray W. Shiraishi
- Division of Global HIV & TB, U.S. Centers for Disease Control & Prevention, Atlanta, United States of America
| | - E. Kainne Dokubo
- Division of Global HIV & TB, U.S. Centers for Disease Control & Prevention, Atlanta, United States of America
| | - Mahesh Swaminathan
- Division of Global HIV & TB, U.S. Centers for Disease Control & Prevention, Atlanta, United States of America
| | - Ibrahim Dalhatu
- Division of Global HIV & TB, U.S. Centers for Disease Control & Prevention, Abuja, Nigeria
| | - Dennis Onotu
- Division of Global HIV & TB, U.S. Centers for Disease Control & Prevention, Abuja, Nigeria
| | - Oseni Abiri
- Division of Global HIV & TB, U.S. Centers for Disease Control & Prevention, Abuja, Nigeria
- School of Biomedical Informatics, University of Texas, Houston, United States of America
| | - Henry Debem
- Division of Global HIV & TB, U.S. Centers for Disease Control & Prevention, Abuja, Nigeria
| | - Adebobola Bashorun
- National AIDS & STIs Control Program, Federal Ministry of Health, Abuja, Nigeria
| | - Tedd V. Ellerbrock
- Division of Global HIV & TB, U.S. Centers for Disease Control & Prevention, Atlanta, United States of America
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Boyer S, Iwuji C, Gosset A, Protopopescu C, Okesola N, Plazy M, Spire B, Orne-Gliemann J, McGrath N, Pillay D, Dabis F, Larmarange J. Factors associated with antiretroviral treatment initiation amongst HIV-positive individuals linked to care within a universal test and treat programme: early findings of the ANRS 12249 TasP trial in rural South Africa. AIDS Care 2017; 28 Suppl 3:39-51. [PMID: 27421051 PMCID: PMC5096681 DOI: 10.1080/09540121.2016.1164808] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Prompt uptake of antiretroviral treatment (ART) is essential to ensure the success of universal test and treat (UTT) strategies to prevent HIV transmission in high-prevalence settings. We describe ART initiation rates and associated factors within an ongoing UTT cluster-randomized trial in rural South Africa. HIV-positive individuals were offered immediate ART in the intervention arm vs. national guidelines recommended initiation (CD4≤350 cells/mm(3)) in the control arm. We used data collected up to July 2015 among the ART-eligible individuals linked to TasP clinics before January 2015. ART initiation rates at one (M1), three (M3) and six months (M6) from baseline visit were described by cluster and CD4 count strata (cells/mm(3)) and other eligibility criteria: ≤100; 100-200; 200-350; CD4>350 with WHO stage 3/4 or pregnancy; CD4>350 without WHO stage 3/4 or pregnancy. A Cox model accounting for covariate effect changes over time was used to assess factors associated with ART initiation. The 514 participants had a median [interquartile range] follow-up duration of 1.08 [0.69; 2.07] months until ART initiation or last visit. ART initiation rates at M1 varied substantially (36.9% in the group CD4>350 without WHO stage 3/4 or pregnancy, and 55.2-71.8% in the three groups with CD4≤350) but less at M6 (from 85.3% in the first group to 96.1-98.3% in the three other groups). Factors associated with lower ART initiation at M1 were a higher CD4 count and attending clinics with both high patient load and higher cluster HIV prevalence. After M1, having a regular partner was the only factor associated with higher likelihood of ART initiation. These findings suggest good ART uptake within a UTT setting, even among individuals with high CD4 count. However, inadequate staffing and healthcare professional practices could result in prioritizing ART initiation in patients with the lowest CD4 counts.
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Affiliation(s)
- Sylvie Boyer
- a INSERM, UMR_S 912, « Sciences Economiques & Sociales de la Santé et Traitement de l'Information Médicale » (SESSTIM) , Marseille , France.,b Aix Marseille Université, UMR_S 912, IRD , Marseille , France
| | - Collins Iwuji
- c Africa Centre for Population Health , University of KwaZulu-Natal , Somkhele , South Africa.,d Research Department of Infection and Population Health , University College London , London , UK
| | - Andréa Gosset
- a INSERM, UMR_S 912, « Sciences Economiques & Sociales de la Santé et Traitement de l'Information Médicale » (SESSTIM) , Marseille , France.,b Aix Marseille Université, UMR_S 912, IRD , Marseille , France.,e ORS PACA, Observatoire Régional de la Santé Provence-Alpes-Côte d'Azur , Marseille , France
| | - Camelia Protopopescu
- a INSERM, UMR_S 912, « Sciences Economiques & Sociales de la Santé et Traitement de l'Information Médicale » (SESSTIM) , Marseille , France.,b Aix Marseille Université, UMR_S 912, IRD , Marseille , France.,e ORS PACA, Observatoire Régional de la Santé Provence-Alpes-Côte d'Azur , Marseille , France
| | - Nonhlanhla Okesola
- c Africa Centre for Population Health , University of KwaZulu-Natal , Somkhele , South Africa
| | - Mélanie Plazy
- f ISPED, Centre Inserm U1219 Bordeaux Population Health, University of Bordeaux , Bordeaux , France.,g INSERM, ISPED, Centre Inserm U1219 Bordeaux Population Health , Bordeaux , France
| | - Bruno Spire
- a INSERM, UMR_S 912, « Sciences Economiques & Sociales de la Santé et Traitement de l'Information Médicale » (SESSTIM) , Marseille , France.,b Aix Marseille Université, UMR_S 912, IRD , Marseille , France.,e ORS PACA, Observatoire Régional de la Santé Provence-Alpes-Côte d'Azur , Marseille , France
| | - Joanna Orne-Gliemann
- f ISPED, Centre Inserm U1219 Bordeaux Population Health, University of Bordeaux , Bordeaux , France.,g INSERM, ISPED, Centre Inserm U1219 Bordeaux Population Health , Bordeaux , France
| | - Nuala McGrath
- c Africa Centre for Population Health , University of KwaZulu-Natal , Somkhele , South Africa.,d Research Department of Infection and Population Health , University College London , London , UK.,h Faculty of Medicine and Faculty of Human, Social and Mathematical Sciences , University of Southampton , Southampton , UK
| | - Deenan Pillay
- c Africa Centre for Population Health , University of KwaZulu-Natal , Somkhele , South Africa.,i Faculty of Medical Sciences , University College London , London , UK
| | - François Dabis
- f ISPED, Centre Inserm U1219 Bordeaux Population Health, University of Bordeaux , Bordeaux , France.,g INSERM, ISPED, Centre Inserm U1219 Bordeaux Population Health , Bordeaux , France
| | - Joseph Larmarange
- c Africa Centre for Population Health , University of KwaZulu-Natal , Somkhele , South Africa.,j CEPED (Centre Population & Développement-UMR 196-Paris Descartes/IRD) , IRD (Institut de Recherche pour le Développement) , Paris , France
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Koenig SP, Dorvil N, Dévieux JG, Hedt-Gauthier BL, Riviere C, Faustin M, Lavoile K, Perodin C, Apollon A, Duverger L, McNairy ML, Hennessey KA, Souroutzidis A, Cremieux PY, Severe P, Pape JW. Same-day HIV testing with initiation of antiretroviral therapy versus standard care for persons living with HIV: A randomized unblinded trial. PLoS Med 2017; 14:e1002357. [PMID: 28742880 PMCID: PMC5526526 DOI: 10.1371/journal.pmed.1002357] [Citation(s) in RCA: 177] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 06/16/2017] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Attrition during the period from HIV testing to antiretroviral therapy (ART) initiation is high worldwide. We assessed whether same-day HIV testing and ART initiation improves retention and virologic suppression. METHODS AND FINDINGS We conducted an unblinded, randomized trial of standard ART initiation versus same-day HIV testing and ART initiation among eligible adults ≥18 years old with World Health Organization Stage 1 or 2 disease and CD4 count ≤500 cells/mm3. The study was conducted among outpatients at the Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic infections (GHESKIO) Clinic in Port-au-Prince, Haiti. Participants were randomly assigned (1:1) to standard ART initiation or same-day HIV testing and ART initiation. The standard group initiated ART 3 weeks after HIV testing, and the same-day group initiated ART on the day of testing. The primary study endpoint was retention in care 12 months after HIV testing with HIV-1 RNA <50 copies/ml. We assessed the impact of treatment arm with a modified intention-to-treat analysis, using multivariable logistic regression controlling for potential confounders. Between August 2013 and October 2015, 762 participants were enrolled; 59 participants transferred to other clinics during the study period, and were excluded as per protocol, leaving 356 in the standard and 347 in the same-day ART groups. In the standard ART group, 156 (44%) participants were retained in care with 12-month HIV-1 RNA <50 copies, and 184 (52%) had <1,000 copies/ml; 20 participants (6%) died. In the same-day ART group, 184 (53%) participants were retained with HIV-1 RNA <50 copies/ml, and 212 (61%) had <1,000 copies/ml; 10 (3%) participants died. The unadjusted risk ratio (RR) of being retained at 12 months with HIV-1 RNA <50 copies/ml was 1.21 (95% CI: 1.04, 1.38; p = 0.015) for the same-day ART group compared to the standard ART group, and the unadjusted RR for being retained with HIV-1 RNA <1,000 copies was 1.18 (95% CI: 1.04, 1.31; p = 0.012). The main limitation of this study is that it was conducted at a single urban clinic, and the generalizability to other settings is uncertain. CONCLUSIONS Same-day HIV testing and ART initiation is feasible and beneficial in this setting, as it improves retention in care with virologic suppression among patients with early clinical HIV disease. TRIAL REGISTRATION This study is registered with ClinicalTrials.gov number NCT01900080.
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Affiliation(s)
- Serena P. Koenig
- Haitian Study Group for Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
- Division of Global Health Equity, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
- * E-mail:
| | - Nancy Dorvil
- Haitian Study Group for Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Jessy G. Dévieux
- AIDS Prevention Program, Florida International University, Miami, Florida, United States of America
| | - Bethany L. Hedt-Gauthier
- Department of Global Health and Social Medicine, Harvard Medical School, Harvard University, Boston, Massachusetts, United States of America
| | - Cynthia Riviere
- Haitian Study Group for Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Mikerlyne Faustin
- Haitian Study Group for Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Kerlyne Lavoile
- Haitian Study Group for Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Christian Perodin
- Haitian Study Group for Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Alexandra Apollon
- Haitian Study Group for Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Limathe Duverger
- Haitian Study Group for Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Margaret L. McNairy
- Center for Global Health, Department of Medicine, Weill Cornell Medical College, Cornell University, New York, New York, United States of America
- Division of General Internal Medicine, Department of Medicine, Weill Cornell Medical College, Cornell University, New York, New York, United States of America
| | - Kelly A. Hennessey
- Haitian Study Group for Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | | | | | - Patrice Severe
- Haitian Study Group for Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Jean W. Pape
- Haitian Study Group for Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
- Center for Global Health, Department of Medicine, Weill Cornell Medical College, Cornell University, New York, New York, United States of America
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Bor J, Ahmed S, Fox MP, Rosen S, Meyer-Rath G, Katz IT, Tanser F, Pillay D, Bärnighausen T. Effect of eliminating CD4-count thresholds on HIV treatment initiation in South Africa: An empirical modeling study. PLoS One 2017; 12:e0178249. [PMID: 28617805 PMCID: PMC5472329 DOI: 10.1371/journal.pone.0178249] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Accepted: 04/21/2017] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND The World Health Organization recommends initiating antiretroviral therapy (ART) regardless of CD4 count. We assessed the effect of ART eligibility on treatment uptake and simulated the impact of WHO's recommendations in South Africa. METHODS We conducted an empirical analysis of cohort data using a regression discontinuity design, and then used this model for policy simulation. We enrolled all patients (n = 19,279) diagnosed with HIV between August 2011 and December 2013 in the Hlabisa HIV Treatment and Care Programme in rural South Africa. Patients were ART-eligible with CD4<350 cells/mm3 or Stage III/IV illness. We estimated: (1) distribution of first CD4 counts in 2013; (2) probability of initiating ART ≤6 months of HIV diagnosis under existing criteria at each CD4 count; (3) probability of initiating ART by CD4 count if thresholds were eliminated; and (4) number of expected new initiators if South Africa eliminates thresholds. FINDINGS In 2013, 38.9% of patients diagnosed had a CD4 count ≥500. 8.0% of these patients initiated even without eligible CD4 counts. If CD4 criteria were eliminated, we project that an additional 19.2% of patients with CD4 ≥500 would initiate ART; 72.8% would not initiate ART despite being eligible. Eliminating CD4 criteria would increase the number starting ART by 26.7%. If these numbers hold nationally, this would represent an additional 164,000 initiators per year, a 5.2% increase in patients receiving ART and 5.3% increase in programme costs. CONCLUSIONS Removing CD4 criteria alone will modestly increase timely uptake of ART. However, our results suggest the majority of newly-eligible patients will not initiate. Improved testing, linkage, and initiation procedures are needed to achieve 90-90-90 targets.
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Affiliation(s)
- Jacob Bor
- Department of Global Health, Boston University School of Public Health, Boston, MA, United States of America
- Africa Health Research Institute, Somkhele and Durban, South Africa
- Health Economics and Epidemiology Research Office, University of Witwatersrand, Johannesburg, South Africa
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, United States of America
| | - Shahira Ahmed
- Department of Global Health, Boston University School of Public Health, Boston, MA, United States of America
- Health Economics and Epidemiology Research Office, University of Witwatersrand, Johannesburg, South Africa
| | - Matthew P. Fox
- Department of Global Health, Boston University School of Public Health, Boston, MA, United States of America
- Health Economics and Epidemiology Research Office, University of Witwatersrand, Johannesburg, South Africa
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, United States of America
| | - Sydney Rosen
- Department of Global Health, Boston University School of Public Health, Boston, MA, United States of America
- Health Economics and Epidemiology Research Office, University of Witwatersrand, Johannesburg, South Africa
| | - Gesine Meyer-Rath
- Department of Global Health, Boston University School of Public Health, Boston, MA, United States of America
- Health Economics and Epidemiology Research Office, University of Witwatersrand, Johannesburg, South Africa
| | - Ingrid T. Katz
- Division of Women’s Health, Brigham and Women’s Hospital, Boston, MA, United States
- Center for Global Health, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
| | - Frank Tanser
- Africa Health Research Institute, Somkhele and Durban, South Africa
| | - Deenan Pillay
- Africa Health Research Institute, Somkhele and Durban, South Africa
- Department of Virology, University College London, London, United Kingdom
| | - Till Bärnighausen
- Africa Health Research Institute, Somkhele and Durban, South Africa
- Heidelberg Institute of Public Health, University of Heidelberg, Heidelberg, Germany
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, United States of America
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Fox MP, Maskew M, Brennan AT, Evans D, Onoya D, Malete G, MacPhail P, Bassett J, Ebrahim O, Mabotja D, Mashamaite S, Long L, Sanne I. Cohort profile: the Right to Care Clinical HIV Cohort, South Africa. BMJ Open 2017; 7:e015620. [PMID: 28601835 PMCID: PMC5724130 DOI: 10.1136/bmjopen-2016-015620] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Revised: 02/26/2017] [Accepted: 04/03/2017] [Indexed: 02/05/2023] Open
Abstract
PURPOSE The research objectives of the Right to Care Clinical HIV Cohort analyses are to: (1) monitor treatment outcomes (including death, loss to follow-up, viral suppression and CD4 count gain among others) for patients on antiretroviral therapy (ART); (2) evaluate the impact of changes in the national treatment guidelines around when to initiate ART on HIV treatment outcomes; (3) evaluate the impact of changes in the national treatment guidelines around what ART regimens to initiate on drug switches; (4) evaluate the cost and cost-effectiveness of HIV treatment delivery models; (5) evaluate the need for and outcomes on second-line and third-line ART; (6) evaluate the impact of comorbidity with non-communicable diseases on HIV treatment outcomes and (7) evaluate the impact of the switch to initiating all patients onto ART regardless of CD4 count. PARTICIPANTS The Right to Care Clinical HIV Cohort is an open cohort of data from 10 clinics in two provinces within South Africa. All clinics include data from 2004 onwards. The cohort currently has data on over 115 000 patients initiated on HIV treatment and patients are followed up every 3-6 months for clinical and laboratory monitoring. FINDINGS TO DATE Cohort data includes information on demographics, clinical visit, laboratory data, medication history and clinical diagnoses. The data have been used to identify rates and predictors of first-line failure, to identify predictors of mortality for patients on second-line (eg, low CD4 counts) and to show that adolescents and young adults are at increased risk of unsuppressed viral loads compared with adults. FUTURE PLANS Future analyses will inform national models of HIV care and treatment to improve HIV care policy in South Africa.
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Affiliation(s)
- Matthew P Fox
- Department of Global Health, Boston University School of Public Health, , Boston , , Massachusetts, , USA
- Department of Epidemiology, Boston University, , Boston , , Massachusetts, , USA
- Department of Medicine, Faculty of Health Sciences, Health Economics and Epidemiology Research Office, University of the Witwatersrand, , Johannesburg , , South Africa
| | - Mhairi Maskew
- Department of Medicine, Faculty of Health Sciences, Health Economics and Epidemiology Research Office, University of the Witwatersrand, , Johannesburg , , South Africa
| | - Alana T Brennan
- Department of Global Health, Boston University School of Public Health, , Boston , , Massachusetts, , USA
- Department of Medicine, Faculty of Health Sciences, Health Economics and Epidemiology Research Office, University of the Witwatersrand, , Johannesburg , , South Africa
- Department of Epidemiology, Boston University, , Boston , , Massachusetts, , USA
| | - Denise Evans
- Department of Medicine, Faculty of Health Sciences, Health Economics and Epidemiology Research Office, University of the Witwatersrand, , Johannesburg , , South Africa
| | - Dorina Onoya
- Department of Medicine, Faculty of Health Sciences, Health Economics and Epidemiology Research Office, University of the Witwatersrand, , Johannesburg , , South Africa
| | - Given Malete
- Department of Medicine, Faculty of Health Sciences, Health Economics and Epidemiology Research Office, University of the Witwatersrand, , Johannesburg , , South Africa
| | - Patrick MacPhail
- Right to Care, , Johannesburg , , South Africa
- Department of Medicine, Clinical HIV Research Unit, University of the Witwatersrand, , Johannesburg , , South Africa
| | - Jean Bassett
- Witkoppen Health and Welfare Centre, , Johannesburg , , South Africa
| | | | | | | | - Lawrence Long
- Department of Medicine, Faculty of Health Sciences, Health Economics and Epidemiology Research Office, University of the Witwatersrand, , Johannesburg , , South Africa
| | - Ian Sanne
- Department of Medicine, Clinical HIV Research Unit, University of the Witwatersrand, , Johannesburg , , South Africa
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Reniers G, Blom S, Calvert C, Martin-Onraet A, Herbst AJ, Eaton JW, Bor J, Slaymaker E, Li ZR, Clark SJ, Bärnighausen T, Zaba B, Hosegood V. Trends in the burden of HIV mortality after roll-out of antiretroviral therapy in KwaZulu-Natal, South Africa: an observational community cohort study. Lancet HIV 2017; 4:e113-e121. [PMID: 27956187 PMCID: PMC5405557 DOI: 10.1016/s2352-3018(16)30225-9] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Revised: 10/13/2016] [Accepted: 10/24/2016] [Indexed: 01/10/2023]
Abstract
BACKGROUND Antiretroviral therapy (ART) substantially decreases morbidity and mortality in people living with HIV. In this study, we describe population-level trends in the adult life expectancy and trends in the residual burden of HIV mortality after the roll-out of a public sector ART programme in KwaZulu-Natal, South Africa, one of the populations with the most severe HIV epidemics in the world. METHODS Data come from the Africa Centre Demographic Information System (ACDIS), an observational community cohort study in the uMkhanyakude district in northern KwaZulu-Natal, South Africa. We used non-parametric survival analysis methods to estimate gains in the population-wide life expectancy at age 15 years since the introduction of ART, and the shortfall of the population-wide adult life expectancy compared with that of the HIV-negative population (ie, the life expectancy deficit). Life expectancy gains and deficits were further disaggregated by age and cause of death with demographic decomposition methods. FINDINGS Covering the calendar years 2001 through to 2014, we obtained information on 93 903 adults who jointly contribute 535 42 8 person-years of observation to the analyses and 9992 deaths. Since the roll-out of ART in 2004, adult life expectancy increased by 15·2 years for men (95% CI 12·4-17·8) and 17·2 years for women (14·5-20·2). Reductions in pulmonary tuberculosis and HIV-related mortality account for 79·7% of the total life expectancy gains in men (8·4 adult life-years), and 90·7% in women (12·8 adult life-years). For men, 9·5% is the result of a decline in external injuries. By 2014, the life expectancy deficit had decreased to 1·2 years for men (-2·9 to 5·8) and to 5·3 years for women (2·6-7·8). In 2011-14, pulmonary tuberculosis and HIV were responsible for 84·9% of the life expectancy deficit in men and 80·8% in women. INTERPRETATION The burden of HIV on adult mortality in this population is rapidly shrinking, but remains large for women, despite their better engagement with HIV-care services. Gains in adult life-years lived as well as the present life expectancy deficit are almost exclusively due to differences in mortality attributed to HIV and pulmonary tuberculosis. FUNDING Wellcome Trust, the Bill & Melinda Gates Foundation, and the National Institutes of Health.
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Affiliation(s)
- Georges Reniers
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK; School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.
| | - Sylvia Blom
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Clara Calvert
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | | | | | - Jeffrey W Eaton
- Department of Infectious Disease Epidemiology, Imperial College London, London, UK
| | - Jacob Bor
- Department of Global Health, Boston University, Boston, MA, USA
| | - Emma Slaymaker
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Zehang R Li
- Department of Statistics, University of Washington, Seattle, WA, USA
| | - Samuel J Clark
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa; Department of Sociology, The Ohio State University, Columbus, OH, USA
| | - Till Bärnighausen
- Africa Health Research Institute, Durban, South Africa; Institute of Public Health, University of Heidelberg, Heidelberg, Germany; Harvard TH Chan School of Public Health, Harvard University, Boston, MA, USA
| | - Basia Zaba
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Victoria Hosegood
- Africa Health Research Institute, Durban, South Africa; Social Statistics and Demography, University of Southampton, Southampton, UK
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Bayer AM, Díaz CM, Chiappe M, Baker AN, Egoavil MS, Pérez-Lu JE, Gorbach PM, García PJ. The odyssey of linking to and staying in HIV care among male sex workers in Peru. JOURNAL OF HIV AND AIDS 2017; 3:10.16966/2380-5536.134. [PMID: 29202049 PMCID: PMC5708583 DOI: 10.16966/2380-5536.134] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND In Peru, there is little information about the HIV care continuum. Therefore, we conducted a study to describe the HIV care continuum among male sex workers (MSWs) in Lima. METHODS We applied close-ended surveys with 209 MSWs about their engagement in the HIV care continuum and open-ended surveys with 34 MSWs who are people living with HIV (PLHIV) to explore their linkage to and retention in HIV care. RESULTS Of 209 MSWs, only 71% (n=148) reported a lifetime HIV test and 56% (n=116) of all MSWs received confirmatory HIV test results. Of the 34 MSWs who are PLHIV, 76% had received HIV care at least once, but only 59% were currently in care, 50% were currently taking ART(antiretroviral therapy) and an even lower 32% had been on ART for 6 months or more. The primary reason for non-linkage to HIV care is the multiple visits to link at the Ministry of Health (MOH). Remaining in care was also challenging, particularly at non-governmental organizations (NGOs). CONCLUSIONS Substantial barriers linking to and remaining in HIV care result in significant delays in linkage and high proportions of PLHIV that remain unlinked or become unstably linked following initial linkage. Urgent implementation science research is needed to facilitate linkage to HIV care and strengthen retention in HIV care post-linkage.
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Affiliation(s)
- Angela M Bayer
- David Geffen School of Medicine, University of California, Los Angeles, 10833 LeConte Ave, CHS 12-105, Los Angeles, CA 90095 and School of Public Health and Administration, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Chanelle M Díaz
- Leonard M. Miller School of Medicine, University of Miami, 1600 NW 10th Ave #1140, Miami, FL 33136
| | - Marina Chiappe
- School of Public Health and Administration, Universidad Peruana Cayetano Heredia, Av. Honorio Delgado 430, San Martin de Porres, Lima, Peru
| | - Amira N Baker
- David Geffen School of Medicine, University of California, Los Angeles, 10833 LeConte Ave, CHS 12-105, Los Angeles, CA 90095
| | - Miguel S Egoavil
- School of Public Health and Administration, Universidad Peruana Cayetano Heredia, Av. Honorio Delgado 430, San Martin de Porres, Lima, Peru
| | - José E Pérez-Lu
- School of Public Health and Administration, Universidad Peruana Cayetano Heredia, Av. Honorio Delgado 430, San Martin de Porres, Lima, Peru
| | - Pamina M Gorbach
- Fielding School of Public Health, University of California, Los Angeles, 10833 LeConte Ave, CHS 41-295, Los Angeles, CA 90095
| | - Patricia J García
- School of Public Health and Administration, Universidad Peruana Cayetano Heredia, Av. Honorio Delgado 430, San Martin de Porres, Lima, Peru
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Katz IT, Bangsberg DR. Cascade of Refusal-What Does It Mean for the Future of Treatment as Prevention in Sub-Saharan Africa? Curr HIV/AIDS Rep 2016; 13:125-30. [PMID: 26894487 DOI: 10.1007/s11904-016-0309-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Recent recommendations by the World Health Organization support treatment for all people living with HIV (PLWH) globally to be initiated at the point of testing. While there has been marked success in efforts to identify and expand treatment for PLWH throughout sub-Saharan Africa, the goal of universal treatment may prove challenging to achieve. The pre-ART phase of the care cascade from HIV testing to HIV treatment initiation includes several social and structural barriers. One such barrier is antiretroviral therapy (ART) treatment refusal, a phenomenon in which HIV-infected individuals choose not to start treatment upon learning their ART eligibility. Our goal is to provide further understanding of why treatment-eligible adults may choose to present for HIV testing but not initiate ART when indicated. In this article, we will discuss factors driving pre-ART loss and present a framework for understanding the impact of decision-making on early losses in the care cascade, with a focus on ART refusal.
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Affiliation(s)
- Ingrid T Katz
- Division of Women's Health, Department of Medicine, Brigham and Women's Hospital, 1620 Tremont St, Boston, MA, 02120, USA. .,Harvard Medical School, Boston, MA, USA. .,Massachusetts General Hospital Center for Global Health, Boston, MA, USA.
| | - David R Bangsberg
- Harvard Medical School, Boston, MA, USA.,Massachusetts General Hospital Center for Global Health, Boston, MA, USA
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High levels of retention in care with streamlined care and universal test and treat in East Africa. AIDS 2016; 30:2855-2864. [PMID: 27603290 DOI: 10.1097/qad.0000000000001250] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE We sought to measure retention in care and identify predictors of nonretention among patients receiving antiretroviral therapy (ART) with streamlined delivery during the first year of the ongoing Sustainable East Africa Research on Community Health (SEARCH) 'test-and-treat' trial (NCT 01864603) in rural Uganda and Kenya. DESIGN Prospective cohort of patients in the intervention arm of the SEARCH study. METHODS We measured retention in care at 12 months among HIV-infected adults who linked to care and were offered ART regardless of CD4 cell count, following community-wide HIV-testing. Kaplan-Meier estimates and Cox proportional hazards modeling were used to calculate the probability of retention at 1 year and identify predictors of nonretention. RESULTS Among 5683 adults (age ≥15) who linked to care, 95.5% [95% confidence interval (CI): 92.9-98.1%] were retained in care at 12 months. The overall probability of retention at 1 year was 89.3% (95% CI: 87.6-90.7%) among patients newly linking to care and 96.4% (95% CI: 95.8-97.0%) among patients previously in care. Younger age and pre-ART CD4 cell count below country treatment initiation guidelines were predictors of nonretention among all patients. Among those newly linking, taking more than 30 days to link to care after HIV diagnosis was additionally associated with nonretention at 1 year. HIV viral load suppression at 12 months was observed in 4227 of 4736 (89%) of patients retained with valid viral load results. CONCLUSION High retention in care and viral suppression after 1 year were achieved in a streamlined HIV care delivery system in the context of a universal test-and-treat intervention.
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Zanoni BC, Archary M, Buchan S, Katz IT, Haberer JE. Systematic review and meta-analysis of the adolescent HIV continuum of care in South Africa: the Cresting Wave. BMJ Glob Health 2016; 1:e000004. [PMID: 28588949 PMCID: PMC5321340 DOI: 10.1136/bmjgh-2015-000004] [Citation(s) in RCA: 107] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Revised: 06/23/2016] [Accepted: 08/08/2016] [Indexed: 11/03/2022] Open
Abstract
CONTEXT South Africa has the most HIV infections of any country in the world, yet little is known about the adolescent continuum of care from HIV diagnosis through viral suppression. OBJECTIVE To determine the adolescent HIV continuum of care in South Africa. DATA SOURCES We searched PubMed, Google Scholar and online conference proceedings from International AIDS Society (IAS), International AIDS Conference (AIDS) and Conference on Retrovirology and Opportunistic Infections (CROI) from 1 January 2005 to 31 July 2015. DATA EXTRACTION We selected published literature containing South African cohorts and epidemiological data reporting primary data for youth (15-24 years of age) at any stage of the HIV continuum of care (ie, diagnosis, treatment, retention, viral suppression). For the meta-analysis we used six sources for retention in care and nine for viral suppression. RESULTS Among the estimated 867 283 HIV-infected youth from 15 to 24 years old in South Africa in 2013, 14% accessed antiretroviral therapy (ART). Of those on therapy, ∼83% were retained in care and 81% were virally suppressed. Overall, we estimate that 10% of HIV-infected youth in South Africa in 2013 were virally suppressed. LIMITATIONS This analysis relies on published data from large mostly urban South Africa cohorts limiting the generalisability to all adolescents. CONCLUSIONS Despite a large increase in ART programmes in South Africa that have relatively high retention rates and viral suppression rates among HIV-infected youth, only a small percentage are virally suppressed, largely due to low numbers of adolescents and young adults accessing ART.
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Affiliation(s)
- Brian C Zanoni
- Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Moherndran Archary
- University of KwaZulu-Natal Nelson Mandela School of Medicine, Durban, South Africa
- Department of Pediatrics, King Edward Hospital, Durban, South Africa
| | - Sarah Buchan
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Ingrid T Katz
- Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jessica E Haberer
- Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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What does preexposure prophylaxis mean for treatment; what does treatment mean for preexposure prophylaxis? Curr Opin HIV AIDS 2016; 11:35-40. [PMID: 26545265 DOI: 10.1097/coh.0000000000000208] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
PURPOSE OF REVIEW Both preexposure prophylaxis (PrEP) and treatment as prevention (TaP) have shown promise in contributing to HIV prevention, in models, observational cohorts and in real-world intervention studies. They share similarities, in that they use the same drugs, toxicity markers and may be focused on the same key populations. How to implement PrEP is still the source of much debate; effective coverage with TaP, with recent data on the positive impact of treatment at high CD4 counts, is still an ongoing challenge. RECENT FINDINGS Treatment has demonstrated individual benefit even at CD4 counts above 350 cells/μl; PrEP has shown the effectiveness in real-world use. SUMMARY This article discusses the intersection of the two interventions, some programmatic misconceptions and complexities, and argues that PrEP is a nuanced and useful adjunct to HIV programmes. PrEP can be rolled out in a way that complements treatment, possibly even within primary health clinics, and may be required for the many people in whom TaP currently fails. PrEP will need constant adaptation so as to maintain programmatic and cost-effectiveness, as the epidemiology of HIV changes with TaP rollout and expansion as CD4 restrictions are lifted. Finally, the article also argues that so-called ethical concerns around competing resources are relatively easily resolved.
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Lippman SA, Shade SB, El Ayadi AM, Gilvydis JM, Grignon JS, Liegler T, Morris J, Naidoo E, Prach LM, Puren A, Barnhart S. Attrition and Opportunities Along the HIV Care Continuum: Findings From a Population-Based Sample, North West Province, South Africa. J Acquir Immune Defic Syndr 2016; 73:91-9. [PMID: 27082505 PMCID: PMC4981507 DOI: 10.1097/qai.0000000000001026] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Attrition along the HIV care continuum slows gains in mitigating the South African HIV epidemic. Understanding population-level gaps in HIV identification, linkage, retention in care, and viral suppression is critical to target programming. METHODS We conducted a population-based household survey, HIV rapid testing, point-of-care CD4 testing, and viral load measurement from dried blood spots using multistage cluster sampling in 2 subdistricts of North West Province from January to March, 2014. We used weighting and multiple imputation of missing data to estimate HIV prevalence, undiagnosed infection, linkage and retention in care, medication adherence, and viral suppression. RESULTS We sampled 1044 respondents aged 18-49. HIV prevalence was 20.0% (95% confidence interval: 13.7 to 26.2) for men and 26.7% (95% confidence interval: 22.1 to 31.4) for women. Among those HIV positive, 48.4% of men and 75.7% of women were aware of their serostatus; 44.0% of men and 74.8% of women reported ever linking to HIV care; 33.1% of men and 58.4% of women were retained in care; and 21.6% of men and 50.0% of women had dried blood spots viral loads <5000 copies per milliliter. Among those already linked to care, 81.7% on antiretroviral treatment (ART) and 56.0% of those not on ART were retained in care, and 51.8% currently retained in care on ART had viral loads <5000 copies per milliliter. CONCLUSIONS Despite expanded treatment in South Africa, attrition along the continuum of HIV care is slowing prevention progress. Improved detection is critically needed, particularly among men. Reported linkage and retention is reasonable for those on ART; however, failure to achieve viral suppression is worrisome.
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Affiliation(s)
- Sheri A. Lippman
- Center for AIDS Prevention Studies, Department of Medicine, University of California, San Francisco, USA
| | - Starley B. Shade
- Center for AIDS Prevention Studies, Department of Medicine, University of California, San Francisco, USA
| | - Alison M. El Ayadi
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, USA
| | | | - Jessica S. Grignon
- Department of Global Health, University of Washington, Seattle, USA
- International Training and Education Center for Health (I-TECH) South Africa, Pretoria, Republic of South Africa
| | - Teri Liegler
- Department of Medicine, University of California, San Francisco, USA
| | - Jessica Morris
- Center for AIDS Prevention Studies, Department of Medicine, University of California, San Francisco, USA
| | - Evasen Naidoo
- International Training and Education Center for Health (I-TECH) South Africa, Pretoria, Republic of South Africa
| | - Lisa M. Prach
- Center for AIDS Prevention Studies, Department of Medicine, University of California, San Francisco, USA
| | - Adrian Puren
- National Institute for Communicable Diseases/NHLS, Johannesburg, South Africa
| | - Scott Barnhart
- Department of Global Health, University of Washington, Seattle, USA
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Hoffmann CJ, Mabuto T, McCarthy K, Maulsby C, Holtgrave DR. A Framework to Inform Strategies to Improve the HIV Care Continuum in Low- and Middle-Income Countries. AIDS EDUCATION AND PREVENTION : OFFICIAL PUBLICATION OF THE INTERNATIONAL SOCIETY FOR AIDS EDUCATION 2016; 28:351-364. [PMID: 27427929 DOI: 10.1521/aeap.2016.28.4.351] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Reasons for attrition along the HIV care continuum are well described. However, improving patient engagement in care has been a challenge. New approaches to understanding and responding to reasons for attrition are required. Here, with a focus on low- and middle-income countries, we propose a framework that brings together an explanatory model with social ecological levels. Individual action may be based on a conscious or unconscious balance between perceived value and perceived costs. When the balance between value and cost favors value, engagement in care can be expected. Value and cost may be mediated by levels of the individual, interpersonal interactions, the clinic experience, community, society, and policy. We encourage the use of a framework for developing strategies to improve the care continuum and believe that this framework provides a rigorous approach.
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Affiliation(s)
- Christopher J Hoffmann
- Johns Hopkins University School of Medicine and Bloomberg School of Public Health, Baltimore, Maryland
- Aurum Institute, Johannesburg, South Africa
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Kelly JD, Schlough GW, Conteh S, Barrie MB, Kargbo B, Giordano TP. The Majority of the Pre-Antiretroviral Population Who Were Lost to Follow-Up Stopped Their Care in Freetown, Sierra Leone: A 12-Month Prospective Cohort Study Starting with HIV Diagnosis. PLoS One 2016; 11:e0149584. [PMID: 26901765 PMCID: PMC4763157 DOI: 10.1371/journal.pone.0149584] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 02/01/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The heterogeneity of the pre-antiretroviral (pre-ART) population calls for more granular depictions of the cascade of HIV care. METHODS We studied a prospective cohort of persons newly diagnosed with HIV infection from a single center in Freetown, Sierra Leone, over a 12-month period and then traced those persons who were lost to follow-up (LTFU) during pre-ART care (before ART initiation). ART eligibility was based on a CD4 cell count result of ≤ 350 mm/cells and/or WHO clinical stage 3 or 4. Persons who attended an appointment in the final three months were considered to be retained in care. Adherence to ART was measured using pharmacy refill dates. "Effective HIV care" was defined as completion of the cascade of care at 12-months regardless of whether patients are on ART. Tracing outcomes were obtained for those who were LTFU during pre-ART care. RESULTS 408 persons newly diagnosed with HIV infection were screened, 338 were enrolled, and 255 persons were staged for ART. ART-ineligible persons had higher retention rates than ART-eligible persons (59.6% vs 41.8%, p = 0.03). 77 (22.8%) of 338 persons received effective HIV care. Most attrition (61.9%) occurred with persons during pre-ART care. 123 of 138 persons (89.1%) who were LTFU prior to ART initiation were found, and 91 of those 123 (74.0%) were alive. Of the 74 persons who were alive and described their engagement in care, 40 (54.1%) stopped care. Nearly half (42.5%) of those 40 stopped after assessment of ART-eligibility but before ART initiation. The main limitation of this study was the lack of tracing outcomes for those lost during ART care. CONCLUSIONS The majority of the pre-ART LTFU population stopped their care, particularly after ART-eligibility but before ART initiation. Interventions to hasten ART initiation and retain this at-risk group may have significant downstream impact on effective HIV care.
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Affiliation(s)
- J. Daniel Kelly
- Department of Medicine, Baylor College of Medicine, Houston, Texas, United States of America
- Wellbody Alliance, Koidu Town, Sierra Leone
- National HIV/AIDS Secretariat, Freetown, Sierra Leone
- * E-mail:
| | | | - Sulaiman Conteh
- National HIV/AIDS Secretariat, Freetown, Sierra Leone
- College of Medicine and Allied Health Sciences of University of Sierra Leone, Freetown, Sierra Leone
| | | | - Brima Kargbo
- National HIV/AIDS Secretariat, Freetown, Sierra Leone
| | - Thomas P. Giordano
- Department of Medicine, Baylor College of Medicine, Houston, Texas, United States of America
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Koenig SP, Bernard D, Dévieux JG, Atwood S, McNairy ML, Severe P, Marcelin A, Julma P, Apollon A, Pape JW. Trends in CD4 Count Testing, Retention in Pre-ART Care, and ART Initiation Rates over the First Decade of Expansion of HIV Services in Haiti. PLoS One 2016; 11:e0146903. [PMID: 26901795 PMCID: PMC4763018 DOI: 10.1371/journal.pone.0146903] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Accepted: 12/23/2015] [Indexed: 12/26/2022] Open
Abstract
Background High attrition during the period from HIV testing to antiretroviral therapy (ART) initiation is widely reported. Though treatment guidelines have changed to broaden ART eligibility and services have been widely expanded over the past decade, data on the temporal trends in pre-ART outcomes are limited; such data would be useful to guide future policy decisions. Methods We evaluated temporal trends and predictors of retention for each step from HIV testing to ART initiation over the past decade at the GHESKIO clinic in Port-au-Prince Haiti. The 24,925 patients >17 years of age who received a positive HIV test at GHESKIO from March 1, 2003 to February 28, 2013 were included. Patients were followed until they remained in pre-ART care for one year or initiated ART. Results 24,925 patients (61% female, median age 35 years) were included, and 15,008 (60%) had blood drawn for CD4 count within 12 months of HIV testing; the trend increased over time from 36% in Year 1 to 78% in Year 10 (p<0.0001). Excluding transfers, the proportion of patients who were retained in pre-ART care or initiated ART within the first year after HIV testing was 84%, 82%, 64%, and 64%, for CD4 count strata ≤200, 201 to 350, 351 to 500, and >500 cells/mm3, respectively. The trend increased over time for each CD4 strata, and in Year 10, 94%, 95%, 79%, and 74% were retained in pre-ART care or initiated ART for each CD4 strata. Predictors of pre-ART attrition included male gender, low income, and low educational status. Older age and tuberculosis (TB) at HIV testing were associated with retention in care. Conclusions The proportion of patients completing assessments for ART eligibility, remaining in pre-ART care, and initiating ART have increased over the last decade across all CD4 count strata, particularly among patients with CD4 count ≤350 cells/mm3. However, additional retention efforts are needed for patients with higher CD4 counts.
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Affiliation(s)
- Serena P. Koenig
- Haitian Study Group for Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
- Division of Global Health Equity, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States of America
- * E-mail:
| | - Daphne Bernard
- Haitian Study Group for Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Jessy G. Dévieux
- AIDS Prevention Program, Florida International University, Miami, FL, United States of America
| | - Sidney Atwood
- Division of Global Health Equity, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Margaret L. McNairy
- Center for Global Health, Weill Cornell Medical College, New York, NY, United States of America
| | - Patrice Severe
- Haitian Study Group for Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Adias Marcelin
- Haitian Study Group for Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Pierrot Julma
- Haitian Study Group for Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Alexandra Apollon
- Haitian Study Group for Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Jean W. Pape
- Haitian Study Group for Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
- Center for Global Health, Weill Cornell Medical College, New York, NY, United States of America
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Use of a Comprehensive HIV Care Cascade for Evaluating HIV Program Performance: Findings From 4 Sub-Saharan African Countries. J Acquir Immune Defic Syndr 2015; 70:e44-51. [PMID: 26375466 DOI: 10.1097/qai.0000000000000745] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND The traditional HIV treatment cascade has been noted to have limitations. A proposed comprehensive HIV care cascade that uses cohort methodology offers additional information as it accounts for all patients. Using data from 4 countries, we compare patient outcomes using both approaches. METHODS Data from 390,603 HIV-infected adults (>15 years) enrolled at 217 facilities in Kenya, Mozambique, Rwanda, and Tanzania from 2005 to 2011 were included. Outcomes of all patients at 3, 6, and 12 months after enrollment were categorized as optimal, suboptimal, or poor. Optimal outcomes included retention in care, antiretroviral therapy (ART) initiation, and documented transfer. Suboptimal outcomes included retention in care without ART initiation among eligible patients or those without eligibility data. Poor outcomes included loss to follow-up and death. RESULTS The comprehensive HIV care cascade demonstrated that at 3, 6 and 12 months, 58%, 51%, and 49% of patients had optimal outcomes; 22%, 12%, and 7% had suboptimal outcomes, and 20%, 37% and 44% had poor outcomes. Of all patients enrolled in care, 56% were retained in care at 12 months after enrollment. In comparison, the traditional HIV treatment cascade found 89% of patients enrolled in HIV care were assessed for ART eligibility, of whom 48% were determined to be ART-eligible with 70% initiating ART, and 78% of those initiated on ART retained at 12 months. CONCLUSIONS The comprehensive HIV care cascade follows outcomes of all patients, including pre-ART patients, who enroll in HIV care over time and uses quality of care parameters for categorizing outcomes. The comprehensive HIV care cascade provides complementary information to that of the traditional HIV treatment cascade and is a valuable tool for monitoring HIV program performance.
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Jefferys LF, Nchimbi P, Mbezi P, Sewangi J, Theuring S. Official invitation letters to promote male partner attendance and couple voluntary HIV counselling and testing in antenatal care: an implementation study in Mbeya Region, Tanzania. Reprod Health 2015; 12:95. [PMID: 26472575 PMCID: PMC4608286 DOI: 10.1186/s12978-015-0084-x] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Accepted: 10/05/2015] [Indexed: 11/10/2022] Open
Abstract
Background The benefits of male partner involvement in antenatal care (ANC) and prevention of mother-to-child transmission of HIV (PMTCT) for maternal and infant health outcomes have been well recognised. However, in many sub-Saharan African settings, male involvement in these services remains low. Previous research has suggested written invitation letters as a way to promote male partner involvement. Methods In this implementation study conducted at three study sites in southwest Tanzania, acceptability of written invitation letters for male partners was assessed. Pre-study CVCT rates of 2–19 % had been recorded at the study sites. Pregnant women approaching ANC without a male partner were given an official letter, inviting the partner to attend a joint ANC and couple voluntary counselling and testing (CVCT) session. Partner attendance was recorded at subsequent antenatal visits, and the invitation was repeated if the partner did not attend. Analysis of socio-demographic indices associated with male partner attendance at ANC was also performed. Results Out of 318 women who received an invitation letter for their partner, 53.5 % returned with their partners for a joint ANC session; of these, 81 % proceeded to CVCT. Self-reported HIV-positive status at baseline was negatively associated with partner return (p = 0.033). Male attendance varied significantly between the rural and urban study sites (p < 0.001) with rates as high as 76 % at the rural site compared to 31 % at the urban health centre. The majority of women assessed the joint ANC session as a favourable experience, however 7 (75 %) of women in HIV-positive discordant or concordant relationships reported problems during mutual disclosure. Beneficial outcomes reported one month after the session included improved client- provider relationship, improved intra-couple communication and enhanced sexual and reproductive health decision-making. Conclusion Official invitation letters are a feasible intervention in a resource limited sub-Saharan African context, they are highly accepted by couple members, and are an effective way to encourage men to attend ANC and CVCT. Pre-intervention CVCT rates were improved in all sites. However, urban settings might require extra emphasis to reach high rates of partner attendance compared to smaller rural health centres.
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Affiliation(s)
- Laura F Jefferys
- Institute of Tropical Medicine and International Health, Charité-Universitätsmedizin, Berlin, Germany.
| | - Philo Nchimbi
- PMTCT Program Mbeya Region, Ministry of Health and Social Welfare, Mbeya, Tanzania.
| | - Paulina Mbezi
- PMTCT Program Mbeya Region, Ministry of Health and Social Welfare, Mbeya, Tanzania.
| | - Julius Sewangi
- Regional AIDS Control Program Mbeya, Ministry of Health and Social Welfare, Mbeya, Tanzania.
| | - Stefanie Theuring
- Institute of Tropical Medicine and International Health, Charité-Universitätsmedizin, Berlin, Germany.
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