Current strategies for improving access and adherence to antiretroviral therapies in resource-limited settings

Intervention strategies to improve adherence to treatment for selected chronic conditions in sub-Saharan Africa: a systematic review

INTRODUCTION

Evidence-based intervention strategies to improve adherence among individuals living with chronic conditions are critical in ensuring better outcomes. In this systematic review, we assessed the impact of interventions that aimed to promote adherence to treatment for chronic conditions.

METHODS

We systematically searched PubMed, Web of Science, Scopus, Google Scholar and CINAHL databases to identify relevant studies published between the years 2000 and 2023 and used the QUIPS assessment tool to assess the quality and risk of bias of each study. We extracted data from eligible studies for study characteristics and description of interventions for the study populations of interest.

RESULTS

Of the 32,698 total studies/records screened, 2814 were eligible for abstract screening and of those, 497 were eligible for full-text screening. A total of 82 studies were subsequently included, describing a total of 58,043 patients. Of the total included studies, 58 (70.7%) were related to antiretroviral therapy for HIV, 6 (7.3%) were anti-hypertensive medication-related, 12 (14.6%) were anti-diabetic medication-related and 6 (7.3%) focused on medication for more than one condition. A total of 54/82 (65.9%) reported improved adherence based on the described study outcomes, 13/82 (15.9%) did not have clear results or defined outcomes, while 15/82 (18.3%) reported no significant difference between studied groups. The 82 publications described 98 unique interventions (some studies described more than one intervention). Among these intervention strategies, 13 (13.3%) were multifaceted (4/13 [30.8%] multi-component health services- and community-based programmes, 6/13 [46.2%] included individual plus group counselling and 3/13 [23.1%] included SMS or alarm reminders plus individual counselling).

DISCUSSION

The interventions described in this review ranged from adherence counselling to more complex interventions such as mobile health (mhealth) interventions. Combined interventions comprised of different components may be more effective than using a single component in isolation. However, the complexity involved in designing and implementing combined interventions often complicates the practicalities of such interventions.

CONCLUSIONS

There is substantial evidence that community- and home-based interventions, digital health interventions and adherence counselling interventions can improve adherence to medication for chronic conditions. Future research should answer if existing interventions can be used to develop less complicated multifaceted adherence intervention strategies.

A bibliometric analysis of HIV nursing research between 1999 and 2022

AIM

Human immunodeficiency virus (HIV) nursing has become more prominent with the increase in chronic HIV infections. This study examined articles related to HIV nursing to determine how the profession has developed and its future direction.

DESIGN

A bibliometric analysis was conducted.

METHODS

HIV nursing-related articles published in the Web of Science core collection between 1999 and 2022 were searched. VOSviewer was used to identify the contributions of countries, institutions and authors in HIV-related care. Collaborative maps, hot topics and keywords trends were analysed using VOSviewer and CiteSpace.

RESULTS

A total of 1513 publications were extracted. An increase in articles published between 1999 and 2012 was observed. After 2012, the increase in the number of publications was relatively stable. Since 2016, a downward trend in the number of publications has occurred. The USA, South Africa and the UK were the leading contributors to publications related to HIV nursing. The focus of the HIV nursing research has gradually shifted from "HIV infection", "risk factors", and "transmission routes" to "social support", "depression", and "public health". The result shows that increased collaboration among countries/regions can improve the development of HIV nursing and effectively reduce the global HIV infection rate. The mental health of patients has become a research centre in the field of HIV nursing. This study provides direction in clinical practice and future research areas in this field.

Enabling Adherence to Treatment (EAT): a pilot study of a combination intervention to improve HIV treatment outcomes among street-connected individuals in western Kenya

BACKGROUND

Street-connected individuals (SCI) in Kenya experience barriers to accessing HIV care. This pilot study provides proof-of-concept for Enabling Adherence to Treatment (EAT), a combination intervention providing modified directly observed therapy (mDOT), daily meals, and peer navigation services to SCI living with HIV or requiring therapy for other conditions (e.g. tuberculosis). The goal of the EAT intervention was to improve engagement in HIV care and viral suppression among SCI living with HIV in an urban setting in Kenya.

METHODS

This pilot study used a single group, pre/post-test design, and enrolled a convenience sample of self-identified SCI of any age. Participants were able to access free hot meals, peer navigation services, and mDOT 6 days per week. We carried out descriptive statistics to characterize participants' engagement in EAT and HIV treatment outcomes. We used McNemar's chi-square test to calculate unadjusted differences in HIV outcomes pre- and post-intervention among participants enrolled in HIV care prior to EAT. We compared unadjusted time to initiation of antiretroviral therapy (ART) and first episode of viral load (VL) suppression among participants enrolled in HIV care prior to EAT vs. concurrently with EAT using the Wilcoxon rank sum test. Statistical significance was defined as p < 0.05. We calculated total, fixed, and variable costs of the intervention.

RESULTS

Between July 2018 and February 2020, EAT enrolled 87 participants: 46 (53%) female and 75 (86%) living with HIV. At baseline, 60 out of 75 participants living with HIV (80%) had previously enrolled in HIV care. Out of 60, 56 (93%) had initiated ART, 44 (73%) were active in care, and 25 (42%) were virally suppressed (VL < 1000 copies/mL) at their last VL measure in the 19 months before EAT. After 19 months of follow-up, all 75 participants living with HIV had enrolled in HIV care and initiated ART, 65 (87%) were active in care, and 44 (59%) were virally suppressed at their last VL measure. Among the participants who were enrolled in HIV care before EAT, there was a significant increase in the proportion who were active in HIV care and virally suppressed at their last VL measure during EAT enrollment compared to before EAT enrollment. Participants who enrolled in HIV care concurrently with EAT had a significantly shorter time to initiation of ART and first episode of viral suppression compared to participants who enrolled in HIV care prior to EAT. The total cost of the intervention over 19 months was USD $57,448.64. Fixed costs were USD $3623.04 and variable costs were USD $63.75/month/participant.

CONCLUSIONS

This pilot study provided proof of concept that EAT, a combination intervention providing mDOT, food, and peer navigation services, was feasible to implement and may support engagement in HIV care and achievement of viral suppression among SCI living with HIV in an urban setting in Kenya. Future work should focus on controlled trials of EAT, assessments of feasibility in other contexts, and cost-effectiveness studies.

Twelve months antiretroviral therapy retention among clients newly enrolled to care and treatment services in Geita Regin, Tanzania: does universal test and treat matter?

Introduction

sustaining high rates of retention is critical for management of HIV clients, newly initiated antiretroviral therapy (ART). In low resource settings including Tanzania, retention among clients on ART was challenging due to inaccessible infrastructure, gender-based violence, inadequate skilled staff and socio-economic disparities. Low retention leads to increased morbidity and mortality. Tanzania adopted universal test and treat (UTT) strategy in mid of 2016 as recommended by Joint United Nations Program on HIV/AIDS (UNAID) that set goals for HIV epidemic control globally. Studies demonstrated controversial findings on whether UTT strategy improves retention, until now there is limited information on the effect of UTT on retaining HIV patients in our settings.

Methods

a retrospective cohort study was conducted between July 2014 to June 2015 and July 2017 to June 2018 to determine 12 months ART retention among clients newly initiated ART prior and during universal test and treat (UTT) strategy in Geita Region, Tanzania. A total of 13,649 newly clients-initiated ART were extracted from the National AIDS control care and treatment database (CTC2 database). Among these clients 4,624 initiated ART prior the UTT strategy and clients 9,025 start ART after the rollout of UTT strategy. Chi-square test was deployed to determine the significant difference of proportion within categories for each UTT group. Kaplan-Meier curve and long rank test were used to determine significant differences of retention rate prior and during UTT program. Cox regression models were used to estimate the association between exposure variables and ART retention with 95% confidence intervals and p-value of p<0.05.

Results

the overall mean age at ART initiation was 38 years (SD=11.6) with observed significant mean difference between two cohorts (prior UTT, mean=41, SD=11.7 Vs during UTT, mean=37, SD=11.3). The cumulative retention was 83.1% among newly initiated ART clients in both cohorts with significant difference observed between two cohorts (69.7% for prior UTT and 89.9% during UTT, p-value<0.001). The overall person year of follow up was 127,209.3 with an incidence rate of ART retention of 86 per 1000 person-year. It was significantly higher among clients enrolled during UTT strategy than clients enrolled prior UTT strategy (95.1 per 1000 PY Vs 69.6 per 1000 PY, p-value<0.001). The log rank test and Kaplan-Meier survival curve demonstrated clients enrolled in the UTT program had greater probability of retention than clients enrolled prior UTT treatment program (log rank X2 test = 599.2, p value < 0.001). Newly HIV clients who initiated ART after the rollout of UTT strategy had 27% higher likelihood to be retained in care and treatment as compared to clients who were enrolled prior UTT strategy, (HR=1.27; 95% CI [1.21 -1.33], p value < 0.001). Sex, District councils, World health Organisation (WHO) stage and client's visit type were significant factors associated with retention among clients newly initiated to care for both arms.

Conclusion

this results, showed that probability of ART retention increased after the rollout of UTT strategy. There is a need to promote universal test and treat strategy in line with other intervention to control HIV epidemic in Geita, Tanzania.

Examining the Relationship Between Psychosocial Factors with Knowledge of HIV-Positive Status and Antiretroviral Therapy Exposure Among Adolescent Girls and Young Women Living with HIV in South Africa

Adolescent girls and young women (AGYW) living with HIV have poor antiretroviral therapy (ART) outcomes. We examined the relationship between psychosocial factors with knowledge of HIV-positive status and antiretroviral therapy exposure among AGYW living with HIV in South Africa. Participants 15-24 years responded to a survey including socio-demographics, psychosocial factors, and HIV testing. Blood was collected to determine HIV status and ART exposure. Multivariable analyses were conducted using R. Of 568 participants with HIV, 356 had knowledge of their HIV-positive status. Social support from family [aOR 1.14 (95% CI 1.04-1.24)] or from a special person [aOR 1.12 (95% CI 1.02-1.23)] was associated with knowledge of HIV-positive status. Resilience [aOR 1.05 (95% CI 1.01-1.08)] was the only psychosocial factor associated with a higher odds of ART exposure. Social support and resilience may increase knowledge of HIV-positive status and ART exposure among South African AGYW.

Effectiveness of community mobilisation models in improving HIV testing services uptake among women and children in Nigeria: A quasi-experimental study

Nigeria carries a high burden of HIV infections, with Taraba State having a prevalence of 2.49%. This quasi-experimental study evaluated the impact of the Lafiyan Yara project, which utilised various community-based mobilisation models, on the enhancement of HTS uptake among women during pregnancy, and children. The intervention involved the implementation of mobilisation by Traditional Birth Attendants (TBA), Village Health Workers (VHW), Patent and Proprietary Medicine Vendors (PPMVs), and a combination of the three in four study local government areas (LGA) in Taraba State. Baseline and end-line surveys were conducted focused on women aged 15-49 years who delivered a child in the past 1 year, and children in their households, in the study and a control LGA. A difference-in-difference (DID) approach was applied by using a probit regression model with interaction terms for treatment status (intervention vs. control) and survey timing to compute the DID estimates of uptake of HTS. The TBA model showed the highest impact in the referral of women to HTS, while the combined model demonstrated the greatest impact in referrals for children. Scaling up and strengthening these community mobilisation efforts can improve access to HIV testing and contribute to HIV/AIDS prevention and control in the region.

Factors affecting adherence to anti-retroviral therapy among women attending HIV clinic of a tertiary health institution in SouthEastern, Nigeria

Background

Strictly adherence to antiretroviral therapy (ART) is needed to achieve viral suppression. Studies have focused on HIV positive pregnant women's adherence. Factors affecting non-pregnant HIV positive women's adherence has been understudied in Enugu.

Objective

The study objective was to identify factors affecting adherence to ART among HIV positive women attending retroviral clinic of a tertiary hospital in Enugu.

Methods

Using a descriptive cross-sectional design, a pre-tested structured questionnaire was used for data collection among 286 HIV positive women aged 18 years and above. Data were analyzed using descriptive statistics of proportions, percentages, and means. Responses with a mean score of ≥2.5 were taken as important factor affecting adherence.

Results

Overall adherence was 56.2%. Participants were considered adherent if they took ≥95% of their prescribed ART. Lack of transport fare (2.69 ±1.36), long-distance to clinic (2.82±1.26), health workers' poor attitude (2.74±1.28), and lack of partners' and parents' support (2.57±1.05) affected adherence negatively while ease in renewing prescription and minimal side effects of drugs enhanced adherence. Enfuvirtide (21.1%) and Lamivudine (17.4%) were drugs that were mostly skipped.

Conclusions

Adherence to ART was low among the women attending the HIV clinic in Enugu. Adherence counseling and education should be provided before ART initiation. Strategies to reduce stigma, increase family support, and improve healthcare providers' attitudes should be employed.

Barriers and facilitators of adherence to antiretroviral treatment at a public health facility in Ghana: a mixed method study

BACKGROUND

HIV/AIDS is a disease of global public health concern with high morbidity and mortality rates. Poor adherence to antiretroviral therapy (ART) increases the risk of viral drug resistance and reduces treatment effectiveness towards viral suppression leading to disease progression, greater risk of death and increased risk of viral transmission. The study sought to assess current adherence levels to ART among patients in Ghana, exploring barriers and enablers of adherence to it, to provide future guidance to all key stakeholder groups.

METHOD

A mixed method approach was used comprising of a cross-sectional survey of patients followed by a focused group discussion with patients and an in-depth interview of four key health professionals working in the ART clinic of Atua Government Hospital, a primary care health facility in the Eastern Region of Ghana. A structured questionnaire was used to assess current adherence levels and their determinants among 231 randomly selected patients attending the clinic between July to September, 2019. Quantitative data were analysed using bivariate and multivariate methods while qualitative data were analysed using thematic framework approach.

RESULTS

Adherence levels was found to be 42.9% among our study population. Lower adherence to ART was associated with patients' belief in herbal medicine (aOR =0.34 CI: 0.19-0.61). Other barriers identified from the qualitative analysis included low motivation arising from pill fatigue, forgetfulness, frequent stock out of medicines, long waiting times and worrying side-effects; while enablers, on the other hand, included measures that ensure improved assessment of adherence and health facility-related activities that improve patient satisfaction with ART services. Conclusion: Adherence to ART among patients living with HIV was sub-optimal in our study population. Understanding of the barriers and factors that enable adherence to ART is a key step to developing evidence-based adherence improvement strategies to enhance clinical outcomes.

Microfinance, retention in care, and mortality among patients enrolled in HIV care in East Africa

OBJECTIVE

To measure associations between participation in community-based microfinance groups, retention in HIV care, and death among people with HIV (PWH) in low-resource settings.

DESIGN AND METHODS

We prospectively analyzed data from 3609 patients enrolled in an HIV care program in western Kenya. HIV patients who were eligible and chose to participate in a Group Integrated Savings for Health Empowerment (GISHE) microfinance group were matched 1 : 2 on age, sex, year of enrollment in HIV care, and location of initial HIV clinic visit to patients not participating in GISHE. Follow-up data were abstracted from medical records from January 2018 through February 2020. Logistic regression analysis examined associations between GISHE participation and two outcomes: retention in HIV care (i.e. >1 HIV care visit attended within 6 months prior to the end of follow-up) and death. Socioeconomic factors associated with HIV outcomes were included in adjusted models.

RESULTS

The study population was majority women (78.3%) with a median age of 37.4 years. Microfinance group participants were more likely to be retained in care relative to HIV patients not participating in a microfinance group [adjusted odds ratio (aOR) = 1.31, 95% confidence interval (CI) 1.01-1.71; P = 0.046]. Participation in group microfinance was associated with a reduced odds of death during the follow-up period (aOR = 0.57, 95% CI 0.28-1.09; P = 0.105).

CONCLUSION

Participation in group-based microfinance appears to be associated with better HIV treatment outcomes. A randomized trial is needed to assess whether microfinance groups can improve clinical and socioeconomic outcomes among PWH in similar settings.

From "Secret" to "Sensitive Issue": Shifting Ideas About HIV Disclosure Among Middle-Aged and Older Rural South Africans in the Era of Antiretroviral Treatment

OBJECTIVE

As HIV shifts from "death sentence" to "chronic condition," disclosure of HIV status to intimate partners and family is a significant component of both prevention and treatment adherence. While disclosure is closely considered in many studies, few examine middle-aged and older persons' (age 40+) perspectives or practices. We trace older rural South Africans' views on HIV disclosure to their partners and family members in a high prevalence community over a period of extensive antiretroviral treatment (ART) rollout.

METHODS

Community focus group discussions (FGD) conducted in 2013 and 2018 show shifts in older persons' thinking about HIV disclosure.

FINDINGS

Our FGD participants saw fewer negative consequences of disclosure in 2018 than in 2013, and highlighted positive outcomes including building trust (partners) as well as greater support for medication collection and adherence (family).

DISCUSSION

Particularly as the epidemic ages in South Africa and globally, tracing changes in older persons' views on disclosure is an important step in developing messaging that could enhance treatment as prevention and ART adherence.

Integrated community-based HIV and non-communicable disease care within microfinance groups in Kenya: study protocol for the Harambee cluster randomised trial

INTRODUCTION

In Kenya, distance to health facilities, inefficient vertical care delivery and limited financial means are barriers to retention in HIV care. Furthermore, the increasing burden of non-communicable diseases (NCDs) among people living with HIV complicates chronic disease treatment and strains traditional care delivery models. Potential strategies for improving HIV/NCD treatment outcomes are differentiated care, community-based care and microfinance (MF).

METHODS AND ANALYSIS

We will use a cluster randomised trial to evaluate integrated community-based (ICB) care incorporated into MF groups in medium and high HIV prevalence areas in western Kenya. We will conduct baseline assessments with n=900 HIV positive members of 40 existing MF groups. Group clusters will be randomised to receive either (1) ICB or (2) standard of care (SOC). The ICB intervention will include: (1) clinical care visits during MF group meetings inclusive of medical consultations, NCD management, distribution of antiretroviral therapy (ART) and NCD medications, and point-of-care laboratory testing; (2) peer support for ART adherence and (3) facility referrals as needed. MF groups randomised to SOC will receive regularly scheduled care at a health facility. Findings from the two trial arms will be compared with follow-up data from n=300 matched controls. The primary outcome will be VS at 18 months. Secondary outcomes will be retention in care, absolute mean change in systolic blood pressure and absolute mean change in HbA1c level at 18 months. We will use mediation analysis to evaluate mechanisms through which MF and ICB care impact outcomes and analyse incremental cost-effectiveness of the intervention in terms of cost per HIV suppressed person-time, cost per patient retained in care and cost per disability-adjusted life-year saved.

ETHICS AND DISSEMINATION

The Moi University Institutional Research and Ethics Committee approved this study (IREC#0003054). We will share data via the Brown University Digital Repository and disseminate findings via publication.

TRIAL REGISTRATION NUMBER

NCT04417127.

Health Care Providers' Challenges to High-Quality HIV Care and Antiretroviral Treatment Retention in Rural South Africa

Provision of high-quality HIV care is challenging, especially in rural primary care clinics in high HIV burden settings. We aimed to better understand the main challenges to quality HIV care provision and retention in antiretroviral treatment (ART) programs in rural South Africa from the health care providers' perspective. We conducted semi-structured qualitative interviews with 23 providers from nine rural clinics. Using thematic and framework analysis, we found that providers and patients face a set of complex and intertwined barriers at the structural, programmatic, and individual levels. More specifically, analyses revealed that their challenges are primarily structural (i.e., health system- and microeconomic context-specific) and programmatic (i.e., clinic- and provider-specific) in nature. We highlight the linkages that providers draw between the challenges they face, the motivation to do their job, the quality of the care they provide, and patients' dissatisfaction with the care they receive, all potentially resulting in poor retention in care.

Immunological Treatment Failure Among Adult Patients Receiving Highly Active Antiretroviral Therapy in East Africa: A Systematic Review and Meta-Analysis

Background

Minimizing antiretroviral treatment failure is crucial for improving patient health and for maintaining long-term access to care in low-income settings such as eastern Africa. To develop interventions to support adherence, policymakers must understand the extent and scope of treatment failure in their programs. However, estimates of treatment failure in eastern Africa have been variable and inconclusive.

Objective

This systematic review and meta-analysis sought to determine the pooled prevalence of immunological failure among adults receiving antiretroviral therapy in eastern Africa.

Methods

We performed a systematic search of the PubMed, Google Scholar, Excerpta Medica Database, and the World Health Organization's Hinari portal (which includes the Scopus, African Index Medicus, and African Journals Online databases) databases. Unpublished studies were also accessed from conference websites and university repositories. We used Stata version 14 for data analysis. The Cochrane Q test and I ² test statistic were used to test for heterogeneity across the studies. Due to high levels of heterogeneity, a random effects model was used to estimate the pooled prevalence of immunological failure. Begg and Egger tests of the intercept in the random effects model were used to check for publication bias.

Results

After removing duplicates, 25 articles remained for assessment and screening. After quality screening, 15 articles were deemed eligible and incorporated into the final analysis. The average pooled estimate of immunological treatment failure prevalence was found to be 21.89% (95% CI, 15.14-28.64). In the subgroup analysis conducted by geographic region, the pooled prevalence of immunological treatment failure in Ethiopia was 15.2% (95% CI, 12.27-18.13) while in Tanzania it was 53.93% (95% CI, 48.14-59.73). Neither the results of Egger test or Begg tests suggested publication bias; however, on visual examination, the funnel plot appeared asymmetric. The large heterogeneity across the studies could be explained by study country.

Conclusion

Immunological treatment failure among patients receiving antiretroviral therapy in eastern Africa was high, and greater than previously reported. The relatively low rates of treatment failure found in Ethiopia suggest that its health extension program should be studied as a model for improving adherence in the region. (Curr Ther Res Clin Exp. 2021; 82:XXX-XXX) © 2021 Elsevier HS Journals, Inc.

Understanding adherence in virally suppressed and unsuppressed human immunodeficiency virus-positive urban patients on second-line antiretroviral treatment

Background

Understanding antiretroviral therapy (ART) adherence may assist in designing effective support interventions.

Objectives

This study elicited perspectives on how to promote treatment adherence from virologically suppressed and unsuppressed patients receiving second-line ART.

Methods

This was a cross-sectional study conducted with randomly selected patients active on second-line ART, from five public health facilities in the Johannesburg inner city. Data were collected on demographics, clinical information, participant’s experiences and ART knowledge. Virological failure was defined as exceeding 1000 copies/mL.

Results

The study sample comprised 149 participants; of which 47.7% (n = 71) were virally unsuppressed and 69.1% (n = 103) were women; the median age of the participants was 42 years (interquartile range [IQR] 36–47 years). Experiencing medication-related difficulties in taking second-line ART (p = 0.003), finding second-line regimen more difficult to take than a first-line regimen (p = 0.001) and experiencing side effects (p < 0.001) were all subjective predictors of virological failure. Participants’ recommendations for improving adherence included the introduction of a single tablet regimen (31.6%, n = 55), reducing the dosage to once daily (26.4%, n = 46) and reducing the pill size for second-line regimen (4.0%, n = 7).

Conclusion

The results of this study highlight the importance of improving patients’ knowledge about adherence and motivation to continue ART use despite the persistence of side effects and difficulties with taking medication.

'Either You Float or You Drown:' The Role of Social Ties and Stigma in Lived Experiences of the HIV Care Continuum in HPTN 065

HPTN 065 utilized financial incentives to promote viral suppression among HIV-positive participants. Exit interviews were conducted in a sub-study of participants in Washington, DC and Bronx, NY. The present analyses explored lived experiences of social ties and stigma as individuals navigated the HIV care continuum, including gender differences in lived experiences. Using viral load data and informed by stages-of-change theory, participants were categorized into "Low-Adherers (n = 13)", "Action (n = 29)" and "Maintenance (n = 31)" stages. Secondary analyses of qualitative data were informed by grounded theory, and instances of social ties and stigma discussed by participants were quantified with descriptive statistics. Participants (N = 73) were mostly male (64%), African American (58%), with yearly income under $10,000 (52%). Low-adherers identified fewer, and sometimes more combative social ties than those in other adherence stages. Maintainers identified supportive ties as motivation for medication adherence (68%) but relied less on them for motivation than individuals in other adherence stages. Low-adherers described current experiences of stigma related to being diagnosed with HIV more than other adherence stages (23%). Individuals in Action reported stigma related to disclosing their HIV status to others (52%), while individuals in Maintenance mostly stigmatized others engaging in "risky" behaviors (32%). Findings suggest that women may perceive greater HIV stigma than men, perceive less supportive social ties, and were the majority of Low-adherers. Gender-informed approaches can facilitate community de-stigmatization of HIV, as African American women may be at greater risk of negative HIV health outcomes.

A cross-sectional study on caregivers' perspective of the quality of life and adherence of paediatric HIV patients to highly active antiretroviral therapy

Background

Poor compliance to highly active antiretroviral therapy (HAART) can result in the poor quality of life in children living with Human immunodeficiency virus/Acquired immunodeficiency syndrome (HIV/AIDS) because of low plasma drug concentration and the possibility of drug resistance. This study evaluates the response of caregivers for determination of adherence and the four quality of life domains in children (aged 14 years and under) on HAART.

Methods

We conducted a cross-sectional study of 188 children, each accompanied by their caregivers at Ola During Children’s Hospital and Makeni Government Hospital between September and November 2016. Adherence to HAART and Quality of life was assessed using the WHO Quality of life summary questionnaire (WHOQOL-BREF). We obtained ethical approval from the Sierra Leone Ethics and Scientific Review Committee.

Results

The study revealed 5.9% adherence amongst paediatric patients, and a strong association of adherent patients(p = 0.019*) to the physical health domain (mean = 64.61 SD = 8.1). Caregiver HIV status showed a strong association with the physical (mean = 58.3, SD = 11.7 and p = 0.024*), and psychological health domains (mean = 68.2, SD = 14.7 and p = 0.001). Caregiver type (mother/father/sibling) accompanying child to hospital also showed strong associated with the physical (mean = 58.0, SD = 10.6, p <  0.001), psychological (mean 68.2 SD = 14.81 p <  0.001) and environmental health domains (mean = 59.7, SD = 13.47, p <  0.001). Further regression analysis showed a strong association with physical health domain for HIV positive caregivers (p = 0.014) and adherent paediatric patients (p = 0.005). Nuclear family also showed a strong association with psychological (p <  0.001) and environmental (p = 0.001) health domains.

Conclusion

This study showed a strong association between the quality of life domains and the involvement of nuclear family caregiver, HIV-positive caregiver and adherence to HAART. Our study suggests that the involvement of any member of the nuclear family, HIV positive parents and patient adherence to therapy can improve the quality of life of paediatric HIV/AIDS patients on highly active antiretroviral therapy in the two hospitals.

Determinants of loss to follow-up among HIV positive patients receiving antiretroviral therapy in a test and treat setting: A retrospective cohort study in Masaka, Uganda

Background

Retaining patients starting antiretroviral therapy (ART) and ensuring good adherence remain cornerstone of long-term viral suppression. In this era of test and treat (T&T) policy, ensuring that patients starting ART remain connected to HIV clinics is key to achieve the UNAIDS 90-90-90 targets. Currently, limited studies have evaluated the effect of early ART initiation on loss to follow up in a routine health care delivery setting. We studied the cumulative incidence, incidence rate of loss to follow up (LTFU), and factors associated with LTFU in a primary healthcare clinic that has practiced T&T since 2012.

Methods

We retrospectively analyzed extracted routine program data on patients who started ART from January 2012 to 4^th July 2016. We defined LTFU as failure of a patient to return to the HIV clinic for at least 90 days from the date of their last appointment. We calculated cumulative incidence, incidence rate and fitted a multivariable Cox proportion hazards regression model to determine factors associated with LTFU.

Results

Of the 7,553 patients included in our sample, 3,231 (42.8%) started ART within seven days following HIV diagnosis. There were 1,180 cases of LTFU observed over 15,807.7 person years at risk. The overall incidence rate (IR) of LTFU was 7.5 (95% CI, 7.1–7.9) per 100 person years of observation (pyo). Cumulative incidence of LTFU increased with duration of follow up from 8.9% (95% CI, 8.2–9.6%) at 6 months to 20.2% (95% CI, 19.0–21.4%) at 48 months. Predictors of elevated risk of LTFU were: starting ART within 7 days following HIV diagnosis ((aHR) = 1.69, 95% CI, 1.50–1.91), lack of a telephone set (aHR = 1.52, 95% CI, 1.35–1.71), CD4 cell count of 200–350μ/ml (aHR = 1.21, 95% CI, 1.01–1.45) and baseline WHO clinical stage 3 or 4 (aHR = 1.35, 95% CI, 1.10–1.65). Factors associated with a reduced risk of LTFU were: baseline age ≥25 years (aHR ranging from 0.62, 95% CI, 0.47–0.81 for age group 25–29 years to 0.24, 95% CI, 0.13–0.44 for age group ≥50 years), at least primary education level (aHR ranging from aHR = 0.77, 95% CI, 0.62–0.94 for primary education level to 0.50, 95% CI, 0.34–0.75 for post-secondary education level), and having a BMI ≥ 30 (aHR = 0.28, 95% CI, 0.15–0.51).

Conclusion

The risk of loss to follow up increased with time and was higher among patients who started ART within seven days following HIV diagnosis, higher among patients without a telephone set, lower among patients aged ≥ 25 years, lower among patients with at least primary education and lower among patients with BMI of ≥ 30. In this era of T&T, it will be important for HIV programs to initiate and continue enhanced therapeutic education programs that target high risk groups, as well as leveraging on mHealth to improve patients’ retention on ART throughout the cascade of care.

Validation of a self-report adherence measurement tool among a multinational cohort of children living with HIV in Kenya, South Africa and Thailand

INTRODUCTION

There are few data on adherence and low-cost measurement tools for children living with HIV. We collected prospective data on adherence to antiretroviral therapy (ART) among a multinational cohort of children to evaluate an adherence questionnaire.

METHODS

We enrolled 319 children ages 0 to 16 years on ART in Kenya (n = 110), South Africa (n = 109) or Thailand (n = 100). Children were followed up for six months of adherence monitoring between March 2015 and August 2016 using Medication Event Monitoring Systems (MEMS^® ) with at least one viral load measure. At month 3 and 6, children or their caregivers were administered a 10-item adherence questionnaire. Repeated measures analyses were used to compare responses on questionnaire items to external adherence criteria: MEMS^® dichotomized adherence (≥90% of doses taken vs. <90%), 48-hour MEMS^® treatment interruptions and viral suppression (<1000 copies/mL). Items associated with outcomes (p < 0.10) were coefficient-weighted to calculate a total adherence score, which was tested in multivariate regression against MEMS^® and viral suppression outcomes. Odds ratios (OR) and 95% confidence intervals (95% CI) were calculated.

RESULTS

Mean child age was 11 years and 54% were female. Children from Thailand (median age 14 years) were significantly older compared to Kenya (10 years) and South Africa (10 years). Prevalence of viral suppression was 97% in Thailand, 81% in South Africa and 69% in Kenya, while the prevalence of MEMS^® adherence ≥90% was 57% in Thailand, 58% in South Africa and 40% in Kenya. Across sites, child-reported adherence using the questionnaire was significantly associated with dichotomized MEMS^® adherence (OR 1.8, 95% CI 1.4 to 2.4), 48-hour treatment interruptions (OR 0.41, 95% CI 0.3 to 0.6), and viral suppression (OR 3.4, 95% CI 1.7 to 6.7). We did find, however, that different cut-points for the adherence score may be context-specific. For example, MEMS^® non-adherent children in Kenya had a lower adherence score (0.98) compared to South Africa (1.77) or Thailand (1.58).

CONCLUSIONS

We found suboptimal adherence to ART was common by multiple measures in this multi-country cohort of children. The short-form questionnaire demonstrated reasonable validity to screen for non-adherence in these diverse settings.

Gay and Bisexual Men's Strategies to Maintain Daily Adherence to Their HIV Pre-exposure Prophylaxis (PrEP) Medication: Results from a Qualitative Study

Since FDA approval in 2012, HIV pre-exposure prophylaxis (PrEP) has been adopted by key populations, including gay and bisexual men (GBM), to reduce their HIV transmission risk. Given that PrEP is optimally effective when taken as prescribed, it is critical to understand the adherence strategies GBM use. We conducted one-on-one, semi-structured interviews with GBM taking PrEP in 2015-2016 (n = 103). Using thematic analysis, we identified six adherence strategies, with most participants (84.3%) utilizing multiple strategies to maintain adequate adherence: (1) integrating PrEP into part of a daily routine, (2) using a pillbox, (3) cognitive strategies/visual cues, (4) setting recurring smartphone alarms or reminders, (5) keeping medication on oneself at all times, and (6) partner or peer support for reminders and/or pill sharing. Overall, participants reported high PrEP adherence (M = 1.6 missed doses in the prior 30 days), though nearly all described missing at least one dose unintentionally in the past. Participants credited their high levels of adherence in part to the strategies they adopted. Providers working with GBM prescribed PrEP, especially patients reporting difficulties with adherence, might consider recommending any or all of the six strategies described in this study.

HIV-1 subtype C predicted co-receptor tropism in Africa: an individual sequence level meta-analysis

Background

Entry inhibitors, such as Maraviroc, hold promise as components of HIV treatment and/or pre-exposure prophylaxis in Africa. Maraviroc inhibits the interaction between HIV Envelope gp120 V3-loop and CCR5 coreceptor. HIV-1 subtype C (HIV-1-C) is predominant in Southern Africa and preferably uses CCR5 co-receptor. Therefore, a significant proportion of HIV-1-C CXCR4 utilizing viruses (X4) may compromise the effectiveness of Maraviroc. This analysis examined coreceptor preferences in early and chronic HIV-1-C infections across Africa.

Methods

African HIV-1-C Envelope gp120 V3-loop sequences sampled from 1988 to 2014 were retrieved from Los Alamos HIV Sequence Database. Sequences from early infections (< 186 days post infection) and chronic infections (> 186 days post infection) were analysed for predicted co-receptor preferences using Geno2Pheno [Coreceptor] 10% FPR, Phenoseq-C, and PSSMsinsi web tools. V3-loop diversity was determined, and viral subtype was confirmed by phylogenetic analysis. National treatment guidelines across Africa were reviewed for Maraviroc recommendation.

Results

Sequences from early (n = 6316) and chronic (n = 7338) HIV-1-C infected individuals from 10 and 15 African countries respectively were available for analyses. Overall, 518/6316 (8.2%; 95% CI 0.7–9.3) of early sequences were X4, with Ethiopia and Malawi having more than 10% each. For chronic infections, 8.3% (95% CI 2.4–16.2) sequences were X4 viruses, with Ethiopia, Tanzania, and Zimbabwe having more than 10% each. For sequences from early chronic infections (< 1 year post infection), the prevalence of X4 viruses was 8.5% (95% CI 2.6–11.2). In late chronic infections (≥ 5 years post infection), X4 viruses were observed in 36% (95% CI − 16.3 to 49.9), with two countries having relatively high X4 viruses: South Africa (43%) and Malawi (24%). The V3-loop amino acid sequence were more variable in X4 viruses in chronic infections compared to acute infections, with South Africa, Ethiopia and Zimbabwe showing the highest levels of V3-loop diversity. All sequences were phylogenetically confirmed as HIV-1-C and clustered according to their co-receptor tropism. In Africa, Maraviroc is registered only in South Africa and Uganda.

Conclusions

Our analyses illustrate that X4 viruses are present in significantly similar proportions in early and early chronic HIV-1 subtype C infected individuals across Africa. In contrast, in late chronic infections, X4 viruses increase 3–5 folds. We can draw two inferences from our observations: (1) to enhance the utility of Maraviroc in chronic HIV subtype C infections in Africa, prior virus co-receptor determination is needed; (2) on the flip side, research on the efficacy of CXCR4 antagonists for HIV-1-C infections is encouraged. Currently, the use of Maraviroc is very limited in Africa.

The effects of decentralising antiretroviral therapy care delivery on health outcomes for adolescents and young adults in low- and middle-income countries: a systematic review

Background: Decentralisation of antiretroviral therapy has been implemented to scale up HIV care provision for patients in resource-limited countries. Youth living with HIV demonstrate the poorest care outcomes, compared to other age groups. Objectives: To systematically evaluate evidence on the effects of decentralising facility-based HIV care on care outcomes for youth living with HIV in low- and middle-income countries. Methods: A systematic review was conducted through 12 electronic databases of peer-reviewed articles, conference abstracts, and grey literature; contacting relevant experts; and hand-searching references. Records were included if they were published after 1 January 1996 (advent of triple-drug ART) and reported health outcomes for decentralised and centralised care, separately, or evaluated the effect of decentralised care on care outcomes. Two authors independently screened search results. When age-disaggregated data (10-24 years old) were required for inclusion, we contacted study authors for data abstraction. Implementation fidelity of decentralisation, study quality, and risk of bias was assessed using the TIDieR checklist, CASP checklists, and ROBINS-I tool, respectively. Results: Of 11 potentially eligible studies, two studies from sub-Saharan Africa met inclusion criteria after data disaggregation by age. The studies and abstracted data were insufficiently homogenous in implementation and study design to justify meta-analysis. However, evidence suggests the potential for decentralised care to result in at least equivalent attrition-related outcomes (retention in care and mortality) for youth within decentralised HIV care. Limited sample size and significant selection and allocation bias confound clear, generalisable conclusions for youth living with HIV in resource-limited settings. Conclusions: There is a paucity of evidence for the effects of decentralising HIV care for youth living in resource-limited settings, particularly recent evidence reflective of the current HIV care landscape. Further work is required to rigorously analyse the effects of decentralising HIV care to inform policymakers and care providers, particularly as demand for HIV care in this population grows.

Mozambique's Community Antiretroviral Therapy Support Group Program: The Role of Social Relationships in Facilitating HIV/AIDS Treatment Retention

The Community Antiretroviral (ARV) Therapy Support Group (CASG) program aims to address low retention rates in Mozambique's HIV treatment program and the absorptive capacity of the country's health facilities. CASG provides patients with the opportunity to form groups, whose members provide peer support and collect ARV medications on a rotating basis for one another. Based on the promising results in one province, a multi-site level evaluation followed. We report on qualitative findings from this evaluation from the patient perspective on the role of social relationships (as facilitated through CASG) in conferring time, financial, educational and psychosocial benefits that contribute to improved patient retention. These findings may be helpful in informing what aspects of social relationships are critical to foster as CASG is implemented within a greater number of Mozambican health facilities, and as other countries design and implement related models of care and treatment with a support group component.

Supporting Adolescents to Adhere (SATA): Lessons learned from an intervention to achieve medication adherence targets among youth living with HIV in Uganda

INTRODUCTION

Youth in Uganda are disproportionately impacted by HIV and report significant barriers to ART adherence. We asked participants how fixed versus flexible adherence target setting for incentive interventions, in combination with other support systems, could help HIV-positive youth in Uganda reach medication adherence targets.

METHODS

Four focus groups conducted in Luganda were audiotaped, transcribed, and translated into English; the transcriptions were then coded using Dedoose software. Two members of the research team read the text and identified the basic topics covered. A codebook was developed that detailed inclusion and exclusion criteria for each topic area, as well as typical entries for each code. A directed content analysis was used to identify key themes.

RESULTS

Several themes were common across groups. Participants consistently maintained that they preferred to set their own adherence targets. But regardless of how adherence targets were assigned, participants noted that missing their target was disappointing. They commented positively on the use of Medication Event Monitoring System (MEMS) caps, noting that knowing their adherence information was being tracked often encouraged them to take their medications. Participants reported that receiving text messages further motivated them to take their medications; however, on occasions when they reported not doing well, they wanted intensive follow-up by staff. Participants said that the prize drawing alone did not motivate their ART adherence and that receiving 'zero' in the drawing was disheartening.

CONCLUSION

We found that participants preferred to set their own adherence targets and that doing so increased a sense of ownership in achieving them. All participants enjoyed using MEMS caps and expressed disappointment at needing to return the device at the study's completion. Participants noted that text message reminders may be a useful way to help patients stay motivated between clinic visits; however, ongoing engagement and support are needed from providers and counselors. Finally, our participants stressed the importance of including incentives with a small, positive value rather than 0 when designing the lowest prize.

Mapping evidence of intervention strategies to improving men's uptake to HIV testing services in sub-Saharan Africa: A systematic scoping review

Background

HIV testing serves as a critical gateway for linkage and retention to care services, particularly in sub-Saharan African countries with high burden of HIV infections. However, the current progress towards addressing the first cascade of the 90–90-90 programme is largely contributed by women. This study aimed to map evidence on the intervention strategies to improve HIV uptake among men in sub-Saharan Africa.

Methods

We conducted a scoping review guided by Arksey and O’Malley’s (2005) framework and Levac et al. (2010) recommendation for methodological enhancement for scoping review studies. We searched for eligible articles from electronic databases such as PubMed/MEDLINE; American Doctoral Dissertations via EBSCO host; Union Catalogue of Theses and Dissertations (UCTD); SA ePublications via SABINET Online; World Cat Dissertations; Theses via OCLC; and Google Scholar. We included studies from January 1990 to August 2018. We used the PRISMA extension for scoping reviews (PRISMA-ScR): checklist and explanation. The Mixed Method Appraisal Tool version 2018 was used to determine the methodological quality of the included studies. We further used NVivo version 11 to aid with content thematic analysis.

Results

This study revealed that teaching men about HIV; Community-Based HIV testing; Home-Based HIV testing; Antenatal Care HIV testing; HIV testing incentives and HIV Self-testing are important strategies to improving HIV testing among men in sub-Saharan Africa. The need for improving programmes aimed at giving more information to men about HIV that are specifically tailored for men, especially given their poor uptake of HIV testing services was also found. This study further revealed the need for implementing Universal Test and Treat among HIV positive men found through community-based testing strategies, while suggesting the importance of restructuring home-based HIV testing visits to address the gap posed by mobile populations.

Conclusion

The community HIV testing, as well as, HIV self-testing strategies showed great potential to increase HIV uptake among men in sub-Saharan Africa. However, to address poor linkage to care, ART should be initiated soon after HIV diagnosis is concluded during community testing services. We also recommend more research aimed at addressing the quality of HIV self-testing kits, as well as, improving the monitoring systems of the distributed HIV self-testing kits.

Electronic supplementary material

The online version of this article (10.1186/s12879-019-4124-y) contains supplementary material, which is available to authorized users.

Availability of integrated family planning services in HIV care and support sites in sub-Saharan Africa: a secondary analysis of national health facility surveys

Background

Integrating family planning (FP) with HIV care and treatment programs is a strategy to expand FP service delivery and prevent unintended pregnancies among women living with HIV. However, little is known about the extent to which FP services are available in health facilities providing HIV services across sub-Saharan Africa. In this study, we assessed the availability of integrated FP services and the associated factors in HIV care and support sites across sub-Saharan Africa.

Methods

We conducted a secondary analysis of nationally representative facility-level data from Service Availability and Readiness Assessments (SARA) and Service Provision Assessments (SPA) conducted in 10 sub-Saharan African countries between 2012 and 2015. We used six indicators that reflect the structure and process of care essential for FP service delivery in HIV care and support facilities to define the outcome of interest - onsite availability of integrated FP services. Multivariate logistic regression was used to explore facility-level characteristics associated with the outcome.

Results

Among the 3161 health facilities offering HIV care and support services, most reported also offering FP services at the same location. The availability of three FP methods was higher than the availability of FP guidelines and trained staff. Onsite availability of integrated FP services ranged from 10 to 61%. Results of multivariate logistic regression indicated that the odds of having onsite integrated FP services available was higher in HIV care and support sites that were operated by the government, classified as a tertiary level care facility, and provided services for PMTCT, antenatal care and basic surgery.

Conclusions

Our findings indicate critical shortcomings in the preparedness of HIV care and support sites to deliver onsite integrated FP services. Renewed efforts are needed to address these supply-side barriers and ensure that integrated FP and HIV services meet the unique needs of HIV clients.

Electronic supplementary material

The online version of this article (10.1186/s12978-019-0713-x) contains supplementary material, which is available to authorized users.

Practices of Care to HIV-Infected Children: Current Situation in Cameroon

Background:

To accelerate access to pediatric HIV care in Cameroon, operational challenges in implementing HIV pediatric care need to be identified. The aim of this study was to assess the knowledge, attitudes, and practices of health care workers regarding pediatric HIV infection in Cameroon.

Methods:

A descriptive cross-sectional study was conducted over a 4-month period (April to August 2014) in 12 health facilities in 7 regions of Cameroon selected using systematic random sampling. Data were collected from interviews with health care providers and managers using standardized self-administered questionnaires and stored in the ACCESS software.

Results:

In total, 103 health care providers were included in this study, of which 59 (57.3%) were health workers and 44 (42.7%) community agents. Most of the health workers in charge of HIV pediatric care were nurses, requiring effective medical task shifting that was institutionalized in Cameroon. The knowledge of health care providers in relation to pediatric HIV care was acceptable. Indications for prescription of test for early infant diagnosis were known (96.1%), but their attitudes and practices regarding initiating antiretroviral therapy (ART) in infants less than 2 years (5.2%) and first-line ART protocols (25.4%) were insufficient, due to little information about standard procedures.

Conclusion:

Capacity building of health care providers and large-scale dissemination of normative national documents are imperative to improve HIV pediatric care in the health care facilities.

Peripheral neuropathy in patients with human immunodeficiency viral infection at a tertiary hospital in Ghana

Peripheral neuropathy (PN) is the most frequent neurological complication in people living with HIV/AIDS. Neurological damage was identified to not only be caused by the viral infection itself but also through neurotoxic antiretroviral therapy (ART). PN is associated with a variety of risk factors; however, detailed knowledge is scarce for sub-Saharan African populations, bearing among the highest HIV/AIDS infection burden.

In a cross-sectional study, we assessed the prevalence of PN in 525 adult outpatients suffering from HIV/AIDS and admitted to the largest tertiary hospital in Ghana. Through a detailed questionnaire and clinical examination including neurologic assessment and laboratory blood sample testing, this study investigated associations of PN with demographic and health determinants and identified risk factors associated with sensory neuropathy.

The prevalence of PN in the Ghanaian cohort was 17.7% and increased odd ratios (OR) when patients were taller (> 1.57 m; OR = 3.84; 95% CI 1.38–10.66) or reached the age > 34 years (p = 0.124). Respondents with longer education duration had significantly less PN (≥ 9 years of education; OR = 0.49; 95% CI 0.26–0.92). The study also identified significant association of PN to both waist and hip girth and neutrophil counts. Curiously, higher adjusted odd ratios (aOR) of PN of patients under ART treatment were observed when CD4 lymphocytes were elevated (aOR = 0.81; 95% CI 0.36–1.83 and aOR = 2.17; 95% CI 0.93–5.05, for 300 and 600 counts, respectively). For patients on ART, an increase of 10 CD4 cell count units increased their chance of developing PN by 1% (aOR = 1.01; 95% CI 1.00 to 1.03).

Despite current drug application regulations, prevalence of PN is still unacceptably high in sub-Saharan African populations. Reduction in chronic morbidity through a health system with routine monitoring, early diagnosis and prompt intervention, and effective case management can improve people living with HIV/AIDS’ quality of life.

"Even if she's really sick at home, she will pretend that everything is fine.": Delays in seeking care and treatment for advanced HIV disease in Kinshasa, Democratic Republic of Congo

INTRODUCTION

HIV prevalence in the Democratic Republic of Congo (DRC) is estimated to be 1.2%, and access to HIV testing and treatment remains low across the country. Despite advances in treatment, HIV continues to be one of the main reasons for hospitalisation and death in low- and middle-income countries, including DRC, but the reasons why people delay seeking health-care when they are extremely sick remain little understood. People in Kinshasa, DRC, continue to present to health-care facilities in an advanced stage of HIV when they are close to death and needing intensive treatment.

METHODS

This qualitative study was conducted in one health-care facility in Kinshasa. A total of 24 in-depth interviews with purposively selected health-care workers, patients and care-givers were conducted. Patients were currently or previously hospitalised with advanced HIV, defined as CD4 count <200 cells/μl. Patients included those who had previously started antiretroviral treatment (ART), and those who had not. Participant observation was also carried out. Interviews were audio-recorded, translated from French and Lingala into English, transcribed, coded and thematically analysed using NVivo.

RESULTS

The main reasons for delaying access to health-care were stigmatisation, religious beliefs and limited economic resources. Stigmatisation meant that people feared disclosing their HIV status and thus did not receive support from their families. Religious leaders were reported to have encouraged people not to take ART. Patients delayed seeking treatment as they could not afford it, and health-care workers believed that staff at other facilities in Kinshasa were delaying HIV diagnoses for economic benefit.

CONCLUSIONS

Delays in accessing care and treatment linked to stigma, religious beliefs and economic factors contribute to explaining the persistence of advanced HIV within this context. Access to free HIV-testing, ART and treatment of opportunistic infections; counselling; training of health-care workers; support for care-givers and stigma reduction strategies are urgently needed to prevent unnecessary deaths.

Results from a proactive follow-up intervention to improve linkage and retention among people living with HIV in Uganda: a pre-/post- study

Background

Despite gains in HIV testing and treatment access in sub-Saharan Africa, patient attrition from care remains a problem. Evidence is needed of real-world implementation of low-cost, scalable, and sustainable solutions to reduce attrition. We hypothesized that more proactive patient follow-up and enhanced counseling by health facilities would improve patient linkage and retention.

Methods

At 20 health facilities in Central Uganda, we implemented a quality of care improvement intervention package that included training lay health workers in best practices for patient follow-up and counseling, including improved appointment recordkeeping, phone calls and home visits to lost patients, and enhanced adherence counseling strategies; and strengthening oversight of these processes. We compared patient linkage to and retention in HIV care in the 9 months before implementation of the intervention to the 9 months after implementation. Data were obtained from facility-based registers and files and analysed using multivariable logistic regression.

Results

Among 1900 patients testing HIV-positive during the study period, there was not a statistically significant increase in linkage to care after implementing the intervention (52.9% versus 54.9%, p = 0.63). However, among 1356 patients initiating antiretroviral therapy during the follow-up period, there were statistically significant increases in patient adherence to appointment schedules (44.5% versus 55.2%, p = 0.01) after the intervention. There was a small increase in Ministry of Health-defined retention in care (71.7% versus 75.7%, p = 0.12); when data from the period of intervention ramp-up was dropped, this increase became statistically significant (71.7% versus 77.6%, p = 0.01). The increase in retention was more dramatic for patients under age 19 years (N = 84; 64.0% versus 83.9%, p = 0.01). The cost per additional patient retained in care was $47.

Conclusions

Improving patient tracking and counseling practices was relatively low cost and enhanced patient retention in care, particularly for pediatric and adolescent patients. This approach should be considered for scale-up in Uganda and elsewhere. However, no impact was seen in improved patient linkage to care with this proactive follow-up intervention.

Trial registration

Pan African Clinical Trial Registry #PACTR201611001756166. Registered August 31, 2016.

Digital Gaming to Improve Adherence Among Adolescents and Young Adults Living With HIV: Mixed-Methods Study to Test Feasibility and Acceptability

Background

An estimated 50% of adolescents and young adults (AYA) living with HIV are failing to adhere to prescribed antiretroviral treatment (ART). Digital games are effective in chronic disease management; however, research on gaming to improve ART adherence among AYA is limited.

Objective

We assessed the feasibility and acceptability of video gaming to improve AYA ART adherence.

Methods

Focus group discussions and surveys were administered to health care providers and AYA aged 13 to 24 years living with HIV at a pediatric HIV program in Washington, DC. During focus group discussions, AYA viewed demonstrations of 3 game prototypes linked to portable Wisepill medication dispensers. Content analysis strategies and thematic coding were used to identify adherence themes and gaming acceptance and feasibility. Likert scale and descriptive statistics were used to summarize response frequencies.

Results

Providers (n=10) identified common adherence barriers and strategies, including use of gaming analogies to improve AYA ART adherence. Providers supported exploration of digital gaming as an adherence intervention. In 6 focus group discussions, 12 AYA participants identified disclosure of HIV status and irregular daily schedules as major barriers to ART and use of alarms and pillboxes as reminders. Most AYA were very or somewhat likely to use the demonstrated game prototypes to help with ART adherence and desired challenging, individually tailored, user-friendly games with in-game incentives. Game prototypes were modified accordingly.

Conclusions

AYA and their providers supported the use of digital games for ART adherence support. Individualization and in-game incentives were preferable and informed the design of an interactive technology-based adherence intervention among AYA living with HIV.

The Standardized Pediatric Expedited Encounters for ART Drugs Initiative (SPEEDI): description and evaluation of an innovative pediatric, adolescent, and young adult antiretroviral service delivery model in Tanzania

BACKGROUND

As countries scale up antiretroviral therapy (ART) for children, innovative strategies to deliver quality services to children are needed. Differentiated ART delivery models have been successful in adults, but no such program has been described in children. We describe the Standardized Pediatric Expedited Encounters for ART Drugs Initiative (SPEEDI).

METHODS

Descriptive analysis of patients eligible for SPEEDI was done via retrospective review of children, adolescents, and young adults on ART at the Baylor Centre of Excellence (COE) in Mbeya, Tanzania between January 2013 and December 2015. Eligibility for SPEEDI visits included the following: stable children, adolescents, and young adults on ART for approximately 3 months or longer, no medical or social complications, good adherence to ART, and presence of reliable caregiver. During a SPEEDI visit, patients were fast tracked in triage to collect medications directly without physically seeing a clinician. SPEEDI patients came to clinic every two months, and alternated SPEEDI visits with standard visits. Baseline characteristics, mortality, and lost-to-follow up rates of SPEEDI patients were analyzed.

RESULTS

One thousand one hundred sixty-four patients utilized SPEEDI, totaling 3493 SPEEDI visits. SPEEDI reached 51.3% (1164/2269) of pediatric ART patients, accounting for 7.7% (3493/44489) of total patient encounters. SPEEDI patients were 52% (605/1164) female, median age of 11.7 years (range 1.2-25.5 yr), median time on ART of 21 months (range 4-130 months) and 83.5% (964/1155) categorized as no or mild HIV-associated immunodeficiency. SPEEDI patients had good outcomes (98.8%), low LTFU (0.1%) and low mortality rates (0.61 deaths per 100 patient-years).

CONCLUSION

SPEEDI was an effective model for delivering ART to children, adolescents, and young adults in our setting, leading to good clinical outcomes, low mortality, and low LTFU. The SPEEDI program safely and effectively expedited and spaced out ART visits for children, adolescents, and young adults, and can serve as an adaptable ART delivery model for other resource limited settings.

Barriers to HIV service utilisation by people living with HIV in two provinces of Zimbabwe: Results from 2016 baseline assessment

Background

The emergence of antiretroviral therapy (ART) transformed HIV from a terminal illness to a chronic disease. However, limited access to health services remains one of many barriers to HIV service utilisation by people living with HIV (PLHIV) in low-resource settings. The goal of this study was to describe the barriers to HIV service utilisation in two provinces of Zimbabwe.

Methods

A qualitative descriptive study was conducted with PLHIV and village health workers (VHW) in eight districts within the two provinces. Convenience sampling was used to select the participants. This sampling was limited to communities supported by health facilities with more than 500 PLHIV enrolled into HIV care and treatment. Interviews were audio-recorded and transcripts were subjected to thematic content analysis.

Results

A total of 22 community focus group discussions (FGDs) were conducted. Barriers to using HIV services cited in PLHIV and VHW FGDs were similar. These were categorised as health system-related barriers, which include user fees, long waiting times, lack of confidentiality and negative attitudes by healthcare providers, and lack of consistent community-based HIV services. Community-related barriers cited were stigma and discrimination, food insecurity, distance to facilities and counterproductive messaging from religious sectors. Client-related factors reported were inadequate male involvement in HIV-related activities and defaulting after symptoms improved.

Conclusion

Our assessment has indicated that there are several barriers to the utilisation of HIV services by PLHIV in the two provinces of Zimbabwe. As new strategies and programmes are being introduced in the current resource-constrained era, efforts should be made to understand the needs of the clients. If programmes are designed with an effort to address some of these challenges, there is a possibility that countries will quickly achieve the 90-90-90 targets set by The Joint United Nations Programme on HIV/AIDS.

Adherence to Highly Active Antiretroviral Therapy Among Children in Ethiopia: A Systematic Review and Meta-analysis

Adherence to highly active antiretroviral therapy (HAART) is the mainstay of the strategy in reducing morbidity and mortality of HIV-infected children. Different primary studies were conducted in Ethiopia. Thus, we aimed to conduct a meta-analysis of the national prevalence of optimal adherence to HAART in children. In addition, associated factors of HAART adherence were reviewed. A weighted inverse variance random-effects model was applied. The 88.7 and 93.7% of children were adhering to HAART at 07 and 03 days prior to an interview respectively. The subgroup analysis showed that HAART adherence was 93.4% in Amhara, 90.1% in Addis Ababa and 87.3% in Tigray at 07 days prior to an interview. Our study suggests that, within short window reported time, adherence to HAART in Ethiopian children may be in a good progress. Emphasis on specific adherence interventions need further based on individual predictors to improve overall HAART adherence of children.

Facilitators and Barriers Affecting Adherence Among People Living With HIV/AIDS: A Qualitative Perspective

Background:

It is widely accepted that for HIV-positive persons on highly active antiretroviral treatment, high levels of adherence to treatment regimens are essential for promoting viral suppression and preventing drug resistance.

Objectives:

This qualitative study examines factors affecting the adherence to HIV/AIDS treatment among patients with HIV/AIDS at a local hospital in Malaysia.

Methods:

The data from purposefully selected patients were collected by in-depth interviews using a pretested interview guide. Saturation was reached at the 13th interview. All interviews were audio-taped and transcribed verbatim for analysis using thematic content analysis.

Results:

Fear and stigma of perceived negative image of HIV diagnosis, lack of disease understating, poor support from the community, and perceived severity or the treatment side effects were among the reasons of nonadherence. Appropriate education and motivation from the doctors and reduction in pill burden were suggested to improve adherence.

Conclusion:

Educational interventions, self-management, and peer and community supports were among the factors suggested to improve adherence. This necessitates uncovering efficient ways to boost doctor–patient communication and recognizing the role of support group for the social and psychological well-being of the patients.

High Acceptability and Increased HIV-Testing Frequency After Introduction of HIV Self-Testing and Network Distribution Among South African MSM

BACKGROUND

South African men who have sex with men (MSM) have a high burden of undiagnosed HIV infection and HIV-testing rates incommensurate with their risk. HIV self-testing (HIVST) may increase testing uptake, frequency, and earlier HIV detection and treatment.

SETTING

Gert Sibande and Ehlanzeni districts, Mpumalanga Province, South Africa.

METHODS

We conducted a longitudinal HIVST study among MSM between June 2015 and May 2017. Overall 127 HIV-negative MSM were provided with up to 9 test kits of their choice-oral fluid or blood fingerstick-to use themselves and distribute to their networks. Surveys conducted 3- and 6-month post-enrollment elicited information on HIVST experiences, preferences, acceptability, utilization, and distribution. We used generalized estimating equations to assess changes in testing frequency.

RESULTS

Ninety-one percent of participants self-tested. All participants who self-tested reported being likely to self-test again, with over 80% preferring HIVST to clinic-based testing. Fingerstick was preferred to oral fluid tests by approximately 2:1. Returning participants distributed 728 tests to sexual partners (18.5% of kits), friends (51.6%), and family (29.8%). Six participants seroconverted during the study, and 40 new diagnoses were reported among test recipients. Frequent (semi-annual) testing increased from 37.8% before the study to 84.5% at follow-up (P < 0.001), and participants reported anticipated frequent testing of 100% if HIVST were available compared with 84% if only clinic-testing were available in the coming year (P < 0.01).

CONCLUSIONS

HIVST use and network distribution is acceptable and feasible for MSM in South Africa and can increase testing uptake and frequency, potentially improving early detection among MSM and their networks.

Cash transfer interventions for sexual health: meanings and experiences of adolescent males and females in inner-city Johannesburg

BACKGROUND

In sub-Saharan Africa, there is growing interest in the use of cash transfer (CT) programs for HIV treatment and prevention. However, there is limited evidence of the consequences related to CT provision to adolescents in low-resourced urban settings. We explored the experiences of adolescents receiving CTs to assess the acceptability and unintended consequences of CT strategies in urban Johannesburg, South Africa.

METHODS

We collected qualitative data during a pilot randomized controlled trial of three CT strategies (monthly payments unconditional vs. conditional on school attendance vs. a once-off payment conditional on a clinic visit) involving 120 adolescents aged 16-18 years old in the inner city of Johannesburg. Interviews were conducted in isiZulu, Sesotho or English with a sub-sample of 49 participants who adhered to study conditions, 6 months after receiving CT (280 ZAR/ 20 USD) and up to 12 months after the program had ended. Interviews were transcribed and translated by three fieldworkers. Codes were generated using an inductive approach; transcripts were initially coded based on emerging issues and subsequently coded deductively using Atlas.ti 7.4.

RESULTS

CTs promoted a sense of independence and an adult social identity amongst recipients. CTs were used to purchase personal and household items; however, there were gender differences in spending and saving behaviours. Male participants' spending reflected their preoccupation with maintaining a public social status through which they asserted an image of the responsible adult. In contrast, female participants' expenditure reflected assumption of domestic responsibilities and independence from older men, with the latter highlighting CTs' potential to reduce transactional sexual partnerships. Cash benefits were short-lived, as adolescents reverted to previous behavior after the program's cessation.

CONCLUSION

CT programs offer adolescent males and females in low-income urban settings a sense of agency, which is vital for their transition to adulthood. However, gender differences in the expenditure of CTs and the effects of ending CT programs must be noted, as these may present potential unintended risks.

FAMILY INTERACTION AND SOCIAL STIGMATIZATION OF PEOPLE LIVING WITH HIV AND AIDS IN PUERTO RICO

This article aims to describe the manifestation of HIV stigma in the family context and how this could impact the life of people living with HIV (PLWH). The data derive from a larger phenomenological study addressing manifestations of stigma in the lives of PLWH when interacting with the health sector. Nine focus groups were carried out in 2011 with PLWH (N=67). Eight themes emerged from the qualitative analysis. For the purpose of this article, we focus on the categories related to family dynamics: the negotiation of disclosure and non-disclosure, fear of the HIV virus and family dynamics, and life as a couple. Socio demographic information showed that 53% were between 44 to 54 years old, 80% were single, 51% were male, 42% did not complete a high school diploma, 82% were unemployed. Also, 82% described themselves as religious persons and 41% had lived with HIV for 10 years or less. Qualitative results show stigma is still present in the family context. PLWH experience fear of disclosure, discrimination, avoid initiating families or couple relationships, experience physical and verbal abuse from relatives, and even separation from other family members. After more than 30 years of the ongoing HIV epidemic, stigma is still manifested by family members with detrimental social and medical implications for PLWH. Research and educational efforts should continue addressing manifestations of stigma among family members of PLWH.

A Framework for Health Communication Across the HIV Treatment Continuum

Supplemental Digital Content is Available in the Text.

Background:

As test and treat rolls out, effective interventions are needed to address the determinants of outcomes across the HIV treatment continuum and ensure that people infected with HIV are promptly tested, initiate treatment early, adhere to treatment, and are virally suppressed. Communication approaches offer viable options for promoting relevant behaviors across the continuum.

Conceptual Framework:

This article introduces a conceptual framework, which can guide the development of effective health communication interventions and activities that aim to impact behaviors across the HIV treatment continuum in low- and medium-income countries. The framework includes HIV testing and counseling, linkage to care, retention in pre-antiretroviral therapy and antiretroviral therapy initiation in one single-stage linkage to care and treatment, and adherence for viral suppression. The determinants of behaviors vary across the continuum and include both facilitators and barriers with communication interventions designed to focus on specific determinants presented in the model. At each stage, relevant determinants occur at the various levels of the social–ecological model: intrapersonal, interpersonal, health services, community, and policy. Effective health communication interventions have mainly relied on mHealth, interpersonal communication through service providers and peers, community support groups, and treatment supporters.

Discussion:

The conceptual framework and evidence presented highlight areas across the continuum where health communication can significantly impact treatment outcomes to reach the 90-90-90 goals by strategically addressing key behavioral determinants. As test and treat rolls out, multifaceted health communication approaches will be critical.

Feasibility of Using HIV Care-Continuum Outcomes to Identify Geographic Areas for Targeted HIV Testing

BACKGROUND

Improved detection and linkage to care of previously undiagnosed HIV infections require innovative approaches to testing. We sought to determine the feasibility of targeted HIV testing in geographic areas, defined by continuum of care parameters, to identify HIV-infected persons needing linkage or engagement in care.

METHODS

Using HIV surveillance data from Washington, DC, we identified census tracts that had an HIV prevalence >1% and were either above (higher risk areas-HRAs) or below (lower risk areas-LRAs) the median for 3 indicators: monitored viral load, proportion of persons out of care (OOC), and never in care. Community-based HIV rapid testing and participant surveys were conducted in the 20 census tracts meeting the criteria. Areas were mapped using ArcGIS, and descriptive and univariate analyses were conducted comparing the areas and participants.

RESULTS

Among 1471 persons tested, 28 (1.9%) tested HIV positive; 2.1% in HRAs vs. 1.7% in LRAs (P = 0.57). Higher proportions of men (63.7% vs. 56.7%, P = 0.007) and fewer blacks (91.0% vs. 94.6%, P = 0.008) were tested in LRAs vs. HRAs; no differences were observed in risk behaviors between the areas. Among HIV-positive participants, 54% were new diagnoses (n = 9) or OOC (n = 6), all were Black, 64% were men with a median age of 51 years.

CONCLUSIONS

Although significant differences in HIV seropositivity were not observed between testing areas, our approach proved feasible and enabled identification of new diagnoses and OOC HIV-infected persons. This testing paradigm could be adapted in other locales to identify areas for targeted HIV testing and other reengagement efforts.

Feasibility of antiretroviral treatment monitoring in the era of decentralized HIV care: a systematic review

BACKGROUND

Regular monitoring of HIV patients who are receiving antiretroviral therapy (ART) is required to ensure patient benefits and the long-term effectiveness and sustainability of ART programs. Prompted by WHO recommendations for expansion and decentralization of HIV treatment and care in low and middle income countries, we conducted a systematic review to assess the feasibility of treatment monitoring in these settings.

METHODS

A comprehensive search strategy was developed using a combination of MeSH and free text terms relevant to HIV treatment and care, health service delivery, health service accessibility, decentralization and other relevant terms. Five electronic databases and two conference websites were searched to identify relevant studies conducted in LMICs, published in English between Jan 2006 and Dec 2015. Outcomes of interest included the proportion of patients who received treatment monitoring and health system factors related to monitoring of patients on ART under decentralized HIV service delivery models.

RESULTS

From 5363 records retrieved, twenty studies were included in the review; all but one was conducted in sub-Saharan African countries. The majority of studies (15/20) had relatively short follow-up duration (≤24 months), and only two studies were specifically designed to assess treatment monitoring practices. The most frequently studied follow-up period was 12 months and a wide range of treatment monitoring coverage was observed. The reported proportions of patients on ART who received CD4 monitoring ranged from very low (6%; N = 2145) to very high (95%; N = 488). The median uptake of viral load monitoring was 86% with studies in program settings reporting coverage as low as 14%. Overall, the longer the follow-up period, the lower the proportion of patients who received regular monitoring tests; and programs in rural areas reported low coverage of laboratory monitoring. Moreover, uptake in the context of research had significantly better where monitoring was done by dedicated research staff. In the absence of point of care (POC) testing, the limited capacity for blood sample transportation between clinic and laboratory and poor quality of nursing staff were identified as a major barrier for treatment monitoring practice.

CONCLUSIONS

There is a paucity of data on the uptake of treatment monitoring, particularly with longer-term follow-up. Wide variation in access to both virological and immunological regular monitoring was observed, with some clinics in well-resourced settings supported by external donors achieving high coverage. The feasibility of treatment monitoring, particularly in decentralized settings of HIV treatment and care may thus be of concern and requires further study. Significant investment in POC diagnostic technologies and, improving the quality of and training for nursing staff is required to ensure effective scale up of ART programs towards the targets of 90-90-90 by the year 2020.

Bottlenecks and opportunities for delivering integrated pediatric HIV services in Nepal

BACKGROUND

In children, integration of HIV in MNCH services has been shown to incr. ease uptake of early infant diagnosis. This article examines bottlenecks and opportunities for scaling up integrated pediatric HIV services in Nepal.

METHODS

This is a descriptive study using both mixed qualitative and quantitative methods, conducted in January 2015 in 19 facilities in five regions of Nepal most affected by HIV epidemic. The qualitative methods comprised in-depth structured interviews with key informants (leadership of The National Center for AIDS and STD Control and National Public Health Laboratory, district management teams, medical officers in charge of health facilities and HIV clinics, frontline staff at antenatal care and HIV clinics and laboratory). The quantitative methods were used to abstract data of HIV-infected pregnant women seen between January and December 2014, HIV-exposed infants aged less than 12 months, and HIV infected children aged less than 15 years who were initiated HIV treatment from 2010 to 2014. Structured tools were used to collect data which were analysed using IBM SPSS.

RESULTS

Of the 19 facilities assessed, 18(98%), 18(98%), 14(75%), and 11(58%) provided prevention of mother-to-child transmission (PMTCT), Expanded Program on Immunization (EPI), pediatric ART and nutrition rehabilitation services, respectively. However, only 1(5%) facility collected onsite dried blood spots (DBS) for PCR HIV testing and 6(32%) facilities provided counselling and referral for DBS. In 2014, of the 121 HIV-exposed infants recorded, only 21(17%) received PCR test. The median turnaround time of the PCR test results was 54 days. Of the 21 records with PCR test, 11(52.5%) were from PMTCT clinics, 7(33%) from Nutritional rehabilitation clinics, and 3(14.5%) from pediatric outpatient clinic.Conversely, 934 children were initiated ART between 2010 and 2014, of which 5% were infants and 29% aged between 1 and 5 years. 298(32%) had comorbidities of which 64% had malnutrition. A total of 534(57%) had tuberculosis (TB) status assessed of which 58(11%) had active TB. Infants had lowest retention (63%), high mortality (17.4%), and loss to follow-up (10.9%).

CONCLUSION

Few facilities collect DBS and few children receive PCR tests with limited linkage to ART. This has led to late ART initiation, comorbidities, including TB coinfections and poor outcomes. The results indicate that there are opportunities for improving HIV case finding among HIV-exposed infants in PMTCT, EPI, TB, and nutrition services if provider initiated testing and counselling at the point of service delivery is institutionalized in these settings.

Facilitators and Barriers of Antiretroviral Therapy Initiation among HIV Discordant Couples in Kenya: Qualitative Insights from a Pre-Exposure Prophylaxis Implementation Study

Introduction

The World Health Organization now recommends antiretroviral therapy (ART) initiation for all HIV-infected individuals regardless of CD4 cell count or disease status. Understanding the facilitators and barriers to initiation of and adherence to ART is essential to successful scale-up of “universal” ART.

Methods

To investigate facilitators and barriers to ART initiation, we conducted 44 in-depth individual or couple interviews with 63 participants (33 participants with HIV and 30 without HIV) already enrolled in a prospective implementation study of oral antiretroviral-based prevention in Kisumu, Kenya between August and September 2014. A semi-structured interview guided discussions on: 1) perceived advantages and disadvantages of ART; 2) reasons for accepting or declining ART initiation; and 3) influence of prevention of transmission to partner or infant influencing ART use. Transcripts from the interviews were iteratively analyzed using inductive content analysis.

Results

HIV-infected participants indicated that living a healthier life, preventing HIV transmission to others, and appearing “normal” or “healthy” again facilitated their initiation of ART. While appearing “normal” allowed these individuals to interact with their communities without stigmatization, they also perceived community opposition to their initiating ART, because appearing “normal” again prevented community members from easily identifying infected individuals in their community. Denial of diagnosis, disclosure stigma, perceived side-effects, and challenges in obtaining refills were additional barriers to ART initiation.

Conclusions

Community perceptions play an important role in both facilitating and inhibiting ART initiation. Perceived stigma, including perceived community opposition to widespread ART use, is an important barrier to ART initiation. Addressing such barriers, while capitalizing on facilitators, to ART initiation should be central to universal ART scale-up efforts.

A systematic review of measures of HIV/AIDS stigma in paediatric HIV-infected and HIV-affected populations

INTRODUCTION

HIV-related stigma impacts the quality of life and care management of HIV-infected and HIV-affected individuals, but how we measure stigma and its impact on children and adolescents has less often been described.

METHODS

We conducted a systematic review of studies that measured HIV-related stigma with a quantitative tool in paediatric HIV-infected and HIV-affected populations.

RESULTS AND DISCUSSION

Varying measures have been used to assess stigma in paediatric populations, with most studies utilizing the full or variant form of the HIV Stigma Scale that has been validated in adult populations and utilized with paediatric populations in Africa, Asia and the United States. Other common measures included the Perceived Public Stigma Against Children Affected by HIV, primarily utilized and validated in China. Few studies implored item validation techniques with the population of interest, although scales were used in a different cultural context from the origin of the scale.

CONCLUSIONS

Many stigma measures have been used to assess HIV stigma in paediatric populations, globally, but few have implored methods for cultural adaptation and content validity.

Prevalent neuropathy in a cohort of HIV-infected Kenyan sex workers using antiretroviral drugs

INTRODUCTION

Several risk factors including stavudine and age have been strongly associated with polyneuropathy. However, conflicting data exist on height as an independent risk factor in polyneuropathy. The objective of this study is to exclude height as an independent polyneuropathy risk factor in a cohort of human immunodeficiency virus (HIV)-infected Kenyan sex workers.

METHODS

This was an analysis of prospectively collected data of treatment-naive subjects initiating either stavudine or tenofovir diphosphate fumarate or zidovudine-based antiretroviral therapy (ART) regimens from January 2008 to August 2012. Polyneuropathy was characterised as burning sensation, numbness, or dysesthesia. The study used arithmetic means of weight (kg) and height (cm) measured in duplicates using calibrated scales.

RESULTS

After exclusion of duplicate data sets and un-confirmed cases of polyneuropathy, the study identified 212 patients without polyneuropathy, 14 pre-ART and 94 post-ART related polyneuropathy cases. Polyneuropathy cases were older but did not differ in demographic, clinical and laboratory parameters at baseline. There was a significant difference in first-line ART regimens with more patients on tenofovir disoproxil fumarate in the post-ART group (p=0.017).

CONCLUSION

Polyneuropathy is a common disorder among HIV-infected Kenyan sex workers. These data cannot support the postulated increased risk by height after matching for gender and ART duration. Though stavudine is associated with polyneuropathy, in this study many patients previously not exposed to stavudine developed polyneuropathy. This suggests the involvement of unknown risk factors such as genetic and metabolite differences in the development of polyneuropathy.

Protocol for a Randomized Controlled Trial Evaluating Mobile Text Messaging to Promote Retention and Adherence to Antiretroviral Therapy for People Living With HIV in Burkina Faso

BACKGROUND

Retention in care and adherence to antiretroviral therapy (ART) among people living with human immunodeficiency virus (PLHIV) is a critical challenge in many African countries including Burkina Faso. Delivering text messaging (short message service, SMS) interventions through mobile phones may help facilitate health service delivery and improve patient health. Despite this potential, no evaluations have been delivered for national scale settings to demonstrate the impact of mobile health (mHealth) for PLHIV.

OBJECTIVES

This study aims to test the impact of SMS text messaging reminders for PLHIV in Burkina Faso, who are under ART. The evaluation identifies whether patients who receive SMS text messages are more likely to (1) retain in care (measured as a dichotomous variable), (2) adhere to antiretroviral regimens (measured as the number of doses missed in the past 7 days), and (3) experience slower disease progression (measured with T-lymphocytes cells). The second objective is to assess its effects on the frequency of health center visits, physical and psychosocial health, nutrition and whether the type of message (text vs image) and frequency (weekly vs semiweekly) have differential impacts including the possibility of message fatigue over time.

METHODS

This 24-month, wide-scale intervention implements a randomized controlled trial (RCT) to evaluate the impact of four variants of a mHealth intervention versus a control group. Our sample comprises adult patients (>15 years of age) undergoing antiretroviral therapy with access to mobile phone services. Multivariate regression analysis will be used to analyze the effect of the intervention on the study population. Data collection is done at baseline and three follow-up waves 6, 12, and 24 months after the intervention starts.

RESULTS

The targeted 3800 patients were recruited between February 2015 and May 2015. But political uncertainty delayed the launch of the intervention until October 2015. Data analysis has not yet started. The first follow-up data collection started in April 2016. To the best of our knowledge, this is the first research that explores the effects of mobile message reminders using a wide-spread sample across an entire nation over a 2-year horizon, especially in a Francophone African country.

CONCLUSIONS

We hypothesize that the interventions have a positive impact on retention in care and adherence to ART schemes and that a more sluggish disease progression will be observed in the short run. However, these benefits may fade out in the long run. The study expects to advance the research on how long mHealth interventions remain effective and when fatigue sets in the context of wide-scale interventions. This information will be useful in designing future wide-scale mHealth interventions in developing countries.

"I Have to Push Him with a Wheelbarrow to the Clinic": Community Health Workers' Roles, Needs, and Strategies to Improve HIV Care in Rural South Africa

With a 19.2% HIV prevalence, South Africa has the largest HIV/AIDS epidemic worldwide. Despite a recent scale-up of public sector HIV resources, including community-based programs to expand HIV care, suboptimal rates of antiretroviral therapy (ART) initiation and adherence persist. As community stakeholders with basic healthcare training, community health workers (CHWs) are uniquely positioned to provide healthcare and insight into potential strategies to improve HIV treatment outcomes. The study goal was to qualitatively explore the self-perceived role of the CHW, unmet CHW needs, and strategies to improve HIV care in rural KwaZulu-Natal, South Africa. Focus groups were conducted in May-August 2014, with 21 CHWs working in Msinga subdistrict. Interviews were audio-recorded, transcribed, and translated from Zulu into English. A hybrid deductive and inductive analytical method borrowed from grounded theory was applied to identify emergent themes. CHWs felt they substantially contributed to HIV care provision but were inadequately supported by the healthcare system. CHWs' recommendations included: (1) sufficiently equipping CHWs to provide education, counseling, social support, routine antiretroviral medication, and basic emergency care, (2) modifying clinical practice to provide less stigmatizing, more patient-centered care, (3) collaborating with traditional healers and church leaders to reduce competition with ART and provide more holistic care, and (4) offsetting socioeconomic barriers to HIV care. In conclusion, CHWs can serve as resources when designing and implementing interventions to improve HIV care. As HIV/AIDS policy and practice evolves in South Africa, it will be important to recognize and formally expand CHWs' roles supporting the healthcare system.

Relationship between Housing Status and Retention Rates among HIV-Positive African Americans Enrolled in a Comprehensive Care Program

Service provision using "one-stop shopping" of medical, psychiatric, and case management services at the same location has been associated with superior client retention. The Yadumu project tested this premise, with attention to HIV-infected African Americans. Each client was assigned a case manager, who arranged meetings with mental health, substance abuse, and medical care professionals. The Center for Mental Health Services, National Outcome Measures (CMHS NOMs) questionnaire was used to evaluate client progress. Data were collected longitudinally and the program evaluation was performed by an outside center. Among 129 clients, 47% were male, 30% were female, and 22% were transgender. The majority (72%) were African American. Clients who lived in detox/drug treatment programs had higher completion rates (48%) than those who were homeless or otherwise housed (28%) (p = 0.04). Logistic regression was used to assess associations between independent factors and retention. Clients satisfied with their housing situation were less likely to retain in the program than those who were not satisfied with their housing situation (OR = 0.15, 95% CI: 0.03-0.78). High discharge rates among HIV-infected people were observed and may reflect the unstable circumstances of the population studied, but structured residential programs could be advantageous for improving retention.

Enrollment in HIV Care Two Years after HIV Diagnosis in the Kingdom of Swaziland: An Evaluation of a National Program of New Linkage Procedures

To improve early enrollment in HIV care, the Swaziland Ministry of Health implemented new linkage procedures for persons HIV diagnosed during the Soka Uncobe male circumcision campaign (SOKA, 2011–2012) and the Swaziland HIV Incidence Measurement Survey (SHIMS, 2011). Abstraction of clinical records and telephone interviews of a retrospective cohort of HIV-diagnosed SOKA and SHIMS clients were conducted in 2013–2014 to evaluate compliance with new linkage procedures and enrollment in HIV care at 92 facilities throughout Swaziland. Of 1,105 clients evaluated, within 3, 12, and 24 months of diagnosis, an estimated 14.0%, 24.3%, and 37.0% enrolled in HIV care, respectively, after adjusting for lost to follow-up and non-response. Kaplan-Meier functions indicated lower enrollment probability among clients 14–24 (P = 0.0001) and 25–29 (P = 0.001) years of age compared with clients >35 years of age. At 69 facilities to which clients were referred for HIV care, compliance with new linkage procedures was low: referral forms were located for less than half (46.8%) of the clients, and few (9.6%) were recorded in the appointment register or called either before (0.3%) or after (4.9%) their appointment. Of over one thousand clients newly HIV diagnosed in Swaziland in 2011 and 2012, few received linkage services in accordance with national procedures and most had not enrolled in HIV care two years after their diagnosis. Our findings are a call to action to improve linkage services and early enrollment in HIV care in Swaziland.

Quality of Care and Service Expansion for HIV Care and Treatment

The last two decades have seen exceptional development of antiretroviral treatment programs throughout the world. Over 14 million persons are accessing antiretroviral treatment (ART) treatment as of early 2015, and life expectancy has risen markedly in the most-affected populations. However, large patient numbers threaten to overwhelm already over-burdened health care systems and retention in care remains suboptimal. Developing innovative strategies to alleviate these burdens and retain patients in care remains a challenge. Furthermore, despite this expansion, large populations of HIV-infected persons remain undiagnosed and are unwilling or unable to access care and treatment programs. Marginalized and high-risk populations are particularly in danger of remaining outside of care and are also disproportionately affected by HIV. To reverse the trend and "fast track" our way out of the epidemic, ambitious treatment targets are required, and a concerted effort has to be made to engage these populations into care, initiate ART, and attain viral suppression.

The role of social support on HIV testing and treatment adherence: A qualitative study of HIV-infected refugees in southwestern Uganda

Little is known about the factors that encourage or discourage refugees to test for HIV, or to access and adhere to HIV care. In non-refugee populations, social support has been shown to influence HIV testing and utilisation of services. The present study enrolled HIV-infected refugees on anti-retroviral therapy (ART) in Uganda, who participated in qualitative interviews on HIV testing, treatment, and adherence. Interviews were analysed for themes about four types of social support: emotional, informational, instrumental, and appraisal support. A total of 61 interviews were analysed. Four roles for these types of social support were identified: (1) informational support encouraged refugees to test for HIV; (2) emotional support helped refugees cope with a diagnosis of HIV; (3) instrumental support facilitated adherence to ART and (4) after diagnosis, HIV-infected refugees provided informational and emotional support to encourage other refugees to test for HIV. These results suggest that social support influences HIV testing and treatment among refugees. Future interventions should capitalise on social support within a refugee settlement to facilitate testing and treatment.