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Lahai M, Theobald S, Wurie HR, Lakoh S, Erah PO, Samai M, Raven J. Factors influencing adherence to antiretroviral therapy from the experience of people living with HIV and their healthcare providers in Sierra Leone: a qualitative study. BMC Health Serv Res 2022; 22:1327. [PMID: 36348488 PMCID: PMC9644013 DOI: 10.1186/s12913-022-08606-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 09/20/2022] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Antiretroviral therapy (ART) is the primary mode of treatment for Human Immunodeficiency Virus (HIV). It slows disease progression and reduces the spread of infection. HIV treatment is also known to require a high level of adherence of over 90% to achieve good treatment outcomes and viral load suppression. In Sierra Leone, about 70% of People Living with HIV (PLHIV) are non-adherent in their first year of treatment. Understanding the reasons behind this high rate of non-adherence from the perspectives of both PLHIV and health workers is critical for developing strategies to improve adherence. This qualitative study is rooted in the field of public health services. It identifies the barriers and facilitators influencing adherence to antiretroviral treatment in Sierra Leone. METHODS: A qualitative study design using in-depth interviews of four healthcare workers and 16 PLHIV in two districts in Sierra Leone- Freetown and Bo. The interviews were analyzed using a grounded theory approach to identify emerging themes from the data. RESULTS The study identified several facilitators and barriers to ART adherence at the personal, community, and health system levels. The facilitators included perceived benefits of ART, family support, having an informal caregiver, receiving free ART medicines, and belonging to peer support groups. The identified barriers were stigma and discrimination, frequency of medication, use of traditional medicine, lack of money for food and transport, work barriers, inadequate medicines and test kits, limited health workers, and long distances to clinics. CONCLUSIONS Our study emphasized the need for implementing behavioural change communication programmes and activities to reduce stigma and discrimination in the community. Knowledge of the facilitators and barriers to antiretroviral therapy could provide relevant information for more responsive and equitable programmes supporting adherence implementation in low- and middle-income countries. This study also identifies the vital need for community integration of HIV treatment services.
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Affiliation(s)
- Michael Lahai
- grid.442296.f0000 0001 2290 9707Faculty of Pharmaceutical Sciences, College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, 00232 Sierra Leone
| | - Sally Theobald
- grid.48004.380000 0004 1936 9764Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Haja R. Wurie
- grid.442296.f0000 0001 2290 9707College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
| | - Sulaiman Lakoh
- grid.442296.f0000 0001 2290 9707College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
| | - Patrick O. Erah
- grid.413068.80000 0001 2218 219XFaculty of Pharmacy, University of Benin, Benin City, Nigeria
| | - Mohamed Samai
- grid.442296.f0000 0001 2290 9707College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
| | - Joanna Raven
- grid.48004.380000 0004 1936 9764Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
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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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Odland ML, Bockarie T, Wurie H, Ansumana R, Lamin J, Nugent R, Bakolis I, Witham M, Davies J. Prevalence and access to care for cardiovascular risk factors in older people in Sierra Leone: a cross-sectional survey. BMJ Open 2020; 10:e038520. [PMID: 32907906 PMCID: PMC7482482 DOI: 10.1136/bmjopen-2020-038520] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION Prevalence of cardiovascular disease risk factors (CVDRFs) is increasing, especially in low-income countries. In Sierra Leone, there is limited empirical data on the prevalence of CVDRFs, and there are no previous studies on the access to care for these conditions. METHODS This study in rural and urban Sierra Leone collected demographic, anthropometric measurements and clinical data from randomly sampled individuals over 40 years old using a household survey. We describe the prevalence of the following risk factors: diabetes, hypertension, dyslipidaemia, overweight or obesity, smoking and having at least one of these risk factors. Cascades of care were constructed for diabetes and hypertension using % of the population with the disease who had previously been tested ('screened'), knew of their condition ('diagnosed'), were on treatment ('treated') or were controlled to target ('controlled'). Multivariable regression was used to test associations between prevalence of CVDRFs and progress through the cascade for hypertension with demographic and socioeconomic variables. In those with recognised disease who did not seek care, reasons for not accessing care were recorded. RESULTS Of 2071 people, 49.6% (95% CI 49.3% to 50.0%) of the population had hypertension, 3.5% (3.4% to 3.6%) had diabetes, 6.7% (6.5% to 7.0%) had dyslipidaemia, 25.6% (25.4% to 25.9%) smoked and 26.5% (26.3% to 26.8%) were overweight/obese; a total of 77.1% (76.6% to 77.5%) had at least one CVDRF. People in urban areas were more likely to have diabetes and be overweight than those living in rural areas. Moreover, being female, more educated or wealthier increased the risk of having all CVDRFs except for smoking. There is a substantial loss of patients at each step of the care cascade for both diabetes and hypertension, with less than 10% of the total population with the conditions being screened, diagnosed, treated and controlled. The most common reasons for not seeking care were lack of knowledge and cost. CONCLUSIONS In Sierra Leone, CVDRFs are prevalent and access to care is low. Health system strengthening with a focus on increased access to quality care for CVDRFs is urgently needed.
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Affiliation(s)
- Maria Lisa Odland
- Institute of Applied Health Research, University of Birmingham, Birmingham, West Midlands, UK
| | - Tahir Bockarie
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Haja Wurie
- College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Western Area, Sierra Leone
| | - Rashid Ansumana
- Mercy Hospital Research Laboratory, Bo, Sierra Leone
- School of Community Health Sciences, Njala University, Bo Campus, Bo, Sierra Leone
| | - Joseph Lamin
- Mercy Hospital Research Laboratory, Bo, Sierra Leone
| | | | - Ioannis Bakolis
- Centre for Implementation Science, Health Services and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Miles Witham
- AGE Research Group, NIHR Newcastle Biomedical Research Centre, Newcastle University, Newcastle upon Tyne, UK
- Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, Newcastle upon Tyne, UK
| | - Justine Davies
- Institute of Applied Health Research, University of Birmingham, Birmingham, West Midlands, UK
- Centre for Global Surgery, Department for Global Health, Stellenbosch University, Stellenbosch, South Africa
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Abebe Moges N, Olubukola A, Micheal O, Berhane Y. HIV patients retention and attrition in care and their determinants in Ethiopia: a systematic review and meta-analysis. BMC Infect Dis 2020; 20:439. [PMID: 32571232 PMCID: PMC7310275 DOI: 10.1186/s12879-020-05168-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Accepted: 06/17/2020] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND There is paucity of evidence on the magnitude of HIV patients' retention and attrition in Ethiopia. Hence, the aim of this study was to determine the pooled magnitude of HIV patient clinical retention and attrition and to identify factors associated with retention and attrition in Ethiopia. METHODS Systematic review and meta-analysis were done among studies conducted in Ethiopia using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. Both published and unpublished studies conducted from January 1, 2005 to June 6th, 2019 were included. Major databases and search engines such as Google Scholar, PUBMED, African Journals Online (AJOL) and unpublished sources were searched to retrieve relevant articles. Data were assessed for quality, heterogeneity and publication bias. Analysis was conducted using STATA version 14 software. RESULT From a total of 45 studies 546,250 study participants were included in this review. The pooled magnitude of retention in care among HIV patients was 70.65% (95% CI, 68.19, 73.11). The overall magnitude of loss to follow up 15.17% (95% CI, 11.86, 18.47), transfer out 11.17% (95% CI, 7.12, 15.21) and death rate were 6.75% (95% CI, 6.22, 7.27). Major determinants of attrition were being unmarried patient (OR 1.52, 95% CI: 1.15-2.01), non-disclosed HIV status (OR 6.36, 95% CI: 3.58-11.29), poor drug adherence (OR 6.60, 95% CI: 1.41-30.97), poor functional status (OR 2.11, 95% CI: 1.33-3.34), being underweight (OR 2.21, 95% CI: 1.45-3.39) and advanced clinical stage (OR 1.85, 95% CI: 1.36-2.51). Whereas absence of opportunistic infections (OR 0.52, 95% CI: 0.30-0.9), normal hemoglobin status (OR 0.29, 95% CI: 0.20-0.42) and non-substance use (OR 95% CI: 0.41, 0.17-0.98) were facilitators of HIV patient retention in clinical care. CONCLUSION The level of retention to the care among HIV patients was low in Ethiopia. Socio-economic, clinical, nutritional and behavioral, intervention is necessary to achieve adequate patient retention in clinical care.
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Affiliation(s)
- Nurilign Abebe Moges
- Department of Public Health, College of Health Sciences, Debre Markos University, Debre Markos, Ethiopia
- Pan African University, Life and Earth Sciences Including Health and Agriculture Institute (PAULESI), University of Ibadan, Ibadan, Nigeria
| | - Adesina Olubukola
- Department of Obstetrics and Gynecology, University College Hospital, University of Ibadan, Ibadan, Nigeria
| | - Okunlola Micheal
- Department of Obstetrics and Gynecology, University College Hospital, University of Ibadan, Ibadan, Nigeria
| | - Yemane Berhane
- Department of Epidemiology, Addis Continental Institute of Public Health, Addis Ababa, Ethiopia
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Retention in Care Trajectories of HIV-Positive Individuals Participating in a Universal Test-and-Treat Program in Rural South Africa (ANRS 12249 TasP Trial). J Acquir Immune Defic Syndr 2019; 80:375-385. [PMID: 30570525 PMCID: PMC6410969 DOI: 10.1097/qai.0000000000001938] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Supplemental Digital Content is Available in the Text. Objective: To study retention in care (RIC) trajectories and associated factors in
patients eligible for antiretroviral therapy (ART) in a universal
test-and-treat setting (TasP trial, South Africa, 2012–2016). Design: A cluster-randomized trial whereby individuals identified HIV positive after
home-based testing were invited to initiate ART immediately (intervention)
or following national guidelines (control). Methods: Exiting care was defined as ≥3 months late for a clinic appointment,
transferring elsewhere, or death. Group-based trajectory modeling was
performed to estimate RIC trajectories over 18 months and associated factors
in 777 ART-eligible patients. Results: Four RIC trajectory groups were identified: (1) group 1
“remained” in care (reference, n = 554, 71.3%), (2) group
2 exited care then “returned” after [median (interquartile
range)] 4 (3–9) months (n = 40, 5.2%), (3) group 3
“exited care rapidly” [after 4 (4–6) months, n =
98, 12.6%], and (4) group 4 “exited care later” [after 11
(9–13) months, n = 85, 10.9%]. Group 2 patients were less likely
to have initiated ART within 1 month and more likely to be male, young
(<29 years), without a regular partner, and to have a CD4 count
>350 cells/mm3. Group 3 patients were more likely to be
women without social support, newly diagnosed, young, and less likely to
have initiated ART within 1 month. Group 4 patients were more likely to be
newly diagnosed and aged 39 years or younger. Conclusions: High CD4 counts at care initiation were not associated with a higher risk of
exiting care. Prompt ART initiation and special support for young and newly
diagnosed patients with HIV are needed to maximize RIC.
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Evaluation of a community-based ART programme after tapering home visits in rural Sierra Leone: a 24-month retrospective study. SAHARA J 2018; 15:138-145. [PMID: 30257611 PMCID: PMC6161614 DOI: 10.1080/17290376.2018.1527244] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Evaluations of community-based antiretroviral therapy (ART) programmes have demonstrated positive outcomes, but little is known about the impact of tapering community-based ART. The objective of this study was to assess 24-month HIV retention outcomes of a community-based ART programme and its tapered visit frequency in Koidu City, Sierra Leone. This retrospective, quasi-experimental study compared outcomes of 52 HIV-infected persons initiated on community-based ART against 91 HIV-infected persons receiving the standard of care from November 2009 to February 2013. The community-based ART pilot programme was designed to strengthen the standard of care through a comprehensive, patient-centred case management strategy. The strategy included medical, educational, psychological, social, and economic support. Starting in October 2011, the frequency of home visits was tapered from twice daily every day per week to once daily three days per week. Outcomes were retention in care at 12 and 24 months and adherence to ART over a three-month time period. Participants who received community-based ART had significantly higher retention than those receiving standard of care. At 12 months, retention rates for community-based ART and standard of care were 61.5% and 31.9%, respectively (p < .01). At 24 months, retention rates for community-based ART and standard of care were 73.1% and 44.0%, respectively (p < .01). Significant differences in levels of adherence were observed when comparing community-based ART against persons receiving standard of care (p < .05). No differences in adherence levels were observed between groups of people receiving various frequencies of home visits. Our pilot programme in Koidu City provides new evidence that community-based ART has the potential to improve retention and adherence outcomes for HIV-infected persons, regardless of the frequency of home visits. Overcoming the barriers to HIV care requires a comprehensive, patient-centred approach that may include clinic-based and community-based interventions.
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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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