Imprisonment for South Ethiopian people living with HIV presents a double health burden: lived experiences of prisoners

BACKGROUND

Optimal adherence is crucial for ensuring both therapeutic and preventative benefits of antiretroviral therapy (ART). Sub-optimal adherence is common in prisoners and little information is available about its predisposing circumstances in resource-limited settings. We explored lived experiences of inmates living with HIV (ILWH) and experiential accounts of service providers in South Ethiopia to identify barriers to and facilitators of HIV care use in the prison context.

METHODS

We conducted qualitative in-depth interviewing with eleven ILWH and eleven service providers. Audio recorded interview data were transcribed verbatim in Amharic language, translated into English and coded based on emerging concepts. We employed a descriptive phenomenological approach to abstract meaning attributed to the prisoners' lived experiences in relation to HIV care use and service providers' experiential account regarding care provision as presented to our consciousness.

FINDINGS

Several concepts emerged as barriers to HIV care use amongst ILWH in South Ethiopia including: limited access to standard care, insufficient health staff support, uncooperative security system, loss of patient privacy, a lack of status disclosure due to social stigma, and food supply insufficiency. In addition to a unique opportunity offered by an imprisonment for some ILWH to refrain from health damaging behaviours, the presence of social support in the prison system facilitated care use.

CONCLUSIONS

This study identified important structural and social contexts that can both hinder and enhance HIV care use amongst ILWH in South Ethiopia. Given the disproportionate burden of HIV in prisoners and the potential of transmission to others during and after incarceration, development of contextually-responsive strategies is required to address the barriers and to also strengthen the enablers.

Factors associated with late initiation of antiretroviral therapy in Iran's HIV/AIDS surveillance data

Early initiation of Antiretroviral Treatment (ART) in HIV patients is essential for effectively suppressing the viral load and prognosis. This study utilized National HIV/AIDS Surveillance Data in Iran to identify factors associated factors with the duration to initiate ART. This hybrid cross-sectional historical cohort study was conducted on Iran's National HIV/AIDS Surveillance Data from 2001 to 2019. Sociodemographic characteristics, route of transmission, HIV diagnosis date, and ART initiation date were collected. Multivariable linear and quantile regression models were employed to analyze the duration to initiate ART by considering predictor variables. This study included 17,062 patients (mean age 34.14 ± 10.77 years, 69.49% males). Multivariate quantile regression coefficients varied across different distributions of the dependent variable (i.e., duration to initiate ART) for several independent variables. Generally, male gender, injecting drug use (IDU), and having an HIV-positive spouse were significantly associated with an increased duration to initiate ART (p < 0.05). However, a significant decrease was observed in older patients, those with a university level education, men who had sex with men (MSM), and patients diagnosed after 2016 (p < 0.05). Despite improvements in the duration to initiate ART after implementing the WHO's 2016 program in Iran, various sociodemographic groups were still vulnerable to delayed ART initiation in the region. Therefore, programs including early testing, early ART initiation, active care, educational and cultural interventions, and appropriate incentives are required for these groups.

Exploring the barriers to the antiretroviral therapy adherence among people living with HIV in Bangladesh: A qualitative approach

INTRODUCTION

Since the evolution of highly active antiretroviral therapy (ART), a near-perfect ART adherence level (>95%) is needed to control viral suppression. Non-adherence to treatment may lead to acquired immunodeficiency syndrome (AIDS) and drug resistance. Though the Bangladesh government provides free treatment and counselling services to people living with human immunodeficiency virus (PLHIV), only 22% of the identified PLHIV continue treatment. Therefore, this study aims to explore the barriers that obstruct the Bangladeshi PLHIV to ensure ART adherence.

METHODS

We conducted a qualitative study in Dhaka, Bangladesh, and recruited the sensitive study population following non-probability, mainly purposive sampling from a community-based registered organization for PLHIV. We conducted the in-depth interview using a semi-structured guideline with 15 consented respondents. We transcribed the audio-recorded interviews in the local language (Bangla) and then translated those into English for data analysis. During the data extraction process, the lead and corresponding authors independently extracted raw data to generate different themes and sub-themes and invited other authors to contribute when they could not solve any discrepancies.

RESULTS

The study identified three significant categories of barriers at the individual, community, and institutional levels that negatively interfered with ART adherence. The most dominant barriers were discrimination and rejection related to stigma, as almost all participants mentioned these barriers. Stigmatizing attitudes and the discriminatory act of the community people and healthcare providers critically affected their treatment adherence. Other leading barriers were improper inventory management of ART-related medicines and CD4 tests and lack of proper counselling. In addition, we found that a positive approach toward life and family support motivated some respondents to overcome the barriers.

CONCLUSIONS

We recommended strengthening Bangladesh's HIV/AIDS prevention, treatment, and management program with a special focus on the improvement of the supply chain of ART-related medicines and CD4 tests and ensuring proper counselling. In addition, we recommended strengthening the behaviour change communication and IEC activities at a large scale to destigmatize health facilities and community levels.

HIV prevalence and continuum of care among incarcerated people in Iran from 2010 to 2017

Background

Incarcerated people are at an increased risk of contracting HIV and transmitting it to the community post-release. In Iran, HIV epidemics inside prisons were first detected in the early 1990s. We assessed the HIV prevalence and its correlates, as well as the continuum of care among incarcerated people in Iran from 2010 to 2017.

Methods

We used data collected in three national bio-behavioral surveillance surveys among incarcerated individuals in 2010 (n = 4,536), 2013 (n = 5,490), and 2017 (n = 5,785) through a multistage cluster sampling approach. HIV was tested by the ELISA method in 2010 and 2013 surveys and rapid tests in 2017. Data on demographic characteristics, risky behaviors, HIV testing, and treatment were collected via face-to-face interviews. HIV prevalence estimates along with 95% confidence intervals (CI) were reported. Using data from the 2017 round, multivariable logistic regression models were built to assess the correlates of HIV sero-positivity and conduct HIV cascade of care analysis.

Results

The HIV prevalence was 2.1% (95% CI: 1.2%, 3.6%) in 2010, 1.7% (95% CI: 1.3%, 2.1%) in 2013, and 0.8% (95% CI: 0.6%, 1.1%) in 2017 (trend P value < 0.001). Among people with a history of injection drug use, HIV prevalence was 8.1% (95% CI: 4.6%, 13.8%) in 2010, 6.3% (95% CI: 4.8%, 8.3%) in 2013, and 3.9% (95% CI: 2.7%, 5.7%) in 2017. In 2017, 64% (32 out of 50) of incarcerated people living with HIV were aware of their HIV status, of whom 45% (9 out of 20) were on antiretroviral therapy, and of whom 44% (4 out of 9) were virally suppressed (< 1000 copies/ml).

Conclusions

While HIV prevalence has decreased among incarcerated people in Iran, their engagement in the HIV continuum of care is suboptimal. Further investments in programs to link incarcerated people to HIV care and retain them in treatment are warranted.

Factors affecting optimal adherence to antiretroviral therapy and viral suppression amongst HIV-infected prisoners in South Ethiopia: a comparative cross-sectional study

BACKGROUND

Maintaining optimal adherence and viral suppression in people living with HIV (PLWH) is essential to ensure both preventative and therapeutic benefits of antiretroviral therapy (ART). Prisoners bear a particularly high burden of HIV infection and are highly likely to transmit to others during and after incarceration. However, the level of treatment adherence and viral suppression in incarcerated populations in low-income countries is unknown. This study aimed to determine factors affecting optimal adherence to antiretroviral therapy and viral suppression amongst HIV-infected prisoners in South Ethiopia.

METHODS

A comparative cross-sectional study was conducted between June 1, 2019 and May 31, 2020 to compare the level of adherence and viral suppression between incarcerated and non-incarcerated PLWH. Patient information including demographic, socio-economic, behavioral, and incarceration-related characteristics were collected using a structured questionnaire. Medication adherence was assessed according to self-report and pharmacy refill. Plasma viral load measurements undertaken within the study period were prospectively extracted to determine viral suppression. Univariate and multivariate logistic and fractional regression models were used to analyse data.

RESULTS

Seventy-four inmates living with HIV (ILWH) and 296 non-incarcerated PLWH participated in the study. While ILWH had a significantly higher pharmacy refill adherence compared to non-incarcerated PLWH (89 vs 75%), they had a slightly lower dose adherence (81% vs 83%). The prevalence of viral non-suppression was also slightly higher in ILWH (6.0%; 95% confidence interval (CI): 1.7-14.6%) compared to non-incarcerated PLWH (4.5%; 95%CI: 2.4-7.5%). Overall, missing ART appointments, dissatisfaction with ART services, inability to comply with a specified medication schedule, and types of methods used to monitor the schedule (e.g., news time on radio/TV or other social cues) were significantly associated with non-adherence according to self-report. In ILWH specifically, accessing ART services from a hospital, inability to properly attend clinic appointments, depressive symptoms, and lack of social support predicted NA. Viral non-suppression was significantly higher in males, people of age 31to 35 years and in those who experienced social stigma, regardless of their incarceration status.

CONCLUSIONS

Sub-optimal dose adherence and viral suppression are generally higher in HIV-infected prisoners in South Ethiopia compared to their non-incarcerated counterparts. A multitude of factors were found to be responsible for this requiring multilevel intervention strategies focusing on the specific needs of prisoners.

A systematic review and meta-analyses on initiation, adherence and outcomes of antiretroviral therapy in incarcerated people

BACKGROUND

Incarcerated people are at increased risk of human immunodeficiency virus (HIV) infection relative to the general population. Despite a high burden of infection, HIV care use among prison populations is often suboptimal and varies among settings, and little evidence exists explaining the discrepancy. Therefore, this review assessed barriers to optimal use of HIV care cascade in incarcerated people.

METHODS

Quantitative and qualitative studies investigating factors affecting linkage to care, ART (antiretroviral therapy) initiation, adherence and/or outcomes among inmates were systematically searched across seven databases. Studies published in English language and indexed up to 26 October 2018 were reviewed. We performed a narrative review for both quantitative and qualitative studies, and meta-analyses on selected quantitative studies. All retrieved quantitative studies were assessed for risk of bias. Meta-analyses were conducted using RevMan-5 software and pooled odds ratios were calculated using Mantel-Haenszel statistics with 95% confidence interval at a p<0.05. The review protocol has been published at the International Prospective Register of Systematic Reviews (PROSPERO; Number: CRD42019135502).

RESULTS

Of forty-two studies included in the narrative review, eight were qualitative studies. Sixteen of the quantitative studies were eligible for meta-analyses. The narrative synthesis revealed structural factors such as: a lack of access to community standard of HIV care, particularly in resource limited countries; loss of privacy; and history of incarceration and re-incarceration as risk factors for poor HIV care use in prison populations. Among social and personal characteristics, lack of social support, stigma, discrimination, substance use, having limited knowledge about, and negative perception towards ART were the main determinants of suboptimal use of care in incarcerated people. In the meta-analyses, lower odds of ART initiation was noticed among inmates with higher baseline CD4 count (CD4 ≥500celss/mm3) (OR = 0.37, 95%CI: 0.14-0.97, I2 = 43%), new HIV diagnosis (OR = 0.07, 95%CI: 0.05-0.10, I2 = 68%), and in those who lacked belief in ART safety (OR = 0.32, 95%CI: 0.18-0.56, I2 = 0%) and efficacy (OR = 0.31, 95%CI: 0.17-0.57, I2 = 0%). Non-adherence was high among inmates who lacked social support (OR = 3.36, 95%CI: 2.03-5.56, I2 = 35%), had low self-efficiency score (OR = 2.50, 95%CI: 1.64,-3.80, I2 = 22%) and those with depressive symptoms (OR = 2.02, 95%CI: 1.34-3.02, I2 = 0%). Lower odds of viral suppression was associated with history of incarceration (OR = 0.40, 95%CI: 0.35-0.46, I2 = 0%), re-incarceration (OR = 0.09, 95%CI: 0.06-0.13, I2 = 64%) and male gender (OR = 0.55, 95%CI: 0.42-0.72, I2 = 0%). Higher odds of CD4 count <200cells/mm3 (OR = 2.01, 95%CI: 1.62, 2.50, I2 = 44%) and lower odds of viral suppression (OR = 0.20, 95%CI: 0.17-0.22, I2 = 0%) were observed during prison entry compared to those noticed during release.

CONCLUSION

Given the high HIV risk in prison populations and rapid movements of these people between prison and community, correctional facilities have the potential to substantially contribute to the use of HIV treatment as a prevention strategy. Thus, there is an urgent need for reviewing context specific interventions and ensuring standard of HIV care in prisons, particularly in resource limited countries.

Association Between Immunologic and Virologic Functioning and Health-Related Quality of Life Among People Living with HIV, Tehran, Iran

BACKGROUND

With recent progress in the treatment of people living with HIV (PLWH) and their increased rate of survival, health-related quality of life (HRQoL) has become an important issue.

OBJECTIVE

In the present study, we aimed to investigate the association of current CD4 cell count, baseline CD4 cell count, nadir CD4 cell count, and plasma viral load with health-related quality of life in PLWH.

METHODS

Participants were 67 PLWH who were under the treatment of antiretroviral therapy (ART) in Imam Khomeini Hospital of Tehran, Iran in 2016. Participants were divided into the two groups with high and low levels of current CD4 cell count, baseline CD4 cell count, nadir CD4 cell count and plasma viral load. We used independent sample t-test for data analysis using SPSS 22 software.

RESULTS

Our results demonstrated that for current CD4 cell count, the group differences were significant for total scores of HRQoL (P=0.028), also in the components of physical functioning (P=0.032), role limitation due to physical health problems (P=0.006), and role limitation due to emotional problems (P=0.009). Our data analysis showed that for baseline CD4 cell count (P=0.62), nadir CD4 cell count (P=0.29), and viral load group (P=0.78), the differences were not significant for HRQoL.

CONCLUSION

Knowing the association between current CD4 count and health-related quality of life, adherence to ART might be a motivator for PLWH to enhance their health-related quality of life.

Barriers and Enablers to HIV Care Among Waria (Transgender Women) in Indonesia: A Qualitative Study

Transgender women (waria) in Indonesia have high rates of HIV and experience barriers accessing HIV services. This qualitative research explored barriers and facilitators to HIV care among waria in Indonesia. Between 2015 and 2016, 42 participants were involved in focus group discussions and in-depth interviews across three urban sites in Indonesia to examine participants' experiences and views on HIV prevention, testing, treatment initiation, and treatment adherence. Data were analyzed thematically. Barriers to accessing HIV care services included perceptions of health and HIV treatment, confidentiality and stigma concerns, and poor access to health insurance. Facilitators to HIV care included recognition of health and perceived susceptibility, perceptions of treatment benefits and consequences of non-adherence, access to social support, and patient-friendly services. Research findings highlight the importance of improving HIV treatment literacy, safeguarding community responses to addressing HIV vulnerability, addressing confidentiality and stigma issues, ensuring services are transgender-friendly, and increasing health insurance coverage.

Experiences of patients with primary HIV diagnosis in Kermanshah-Iran regarding the nature of HIV/AIDS: A qualitative study

Background

A diagnosis of HIV (human immunodeficiency virus) infection causes a wide range of mental challenges regarding the meaning and understanding of such a diagnosis because of the specific nature of HIV and its social consequences. AIDS patients perceived their disease as multidimensional Stigma and rejection and even discrimination and insult in receiving health services. Therefore, a deep awareness and understanding of an individual's meaning and interpretation of a HIV-positive diagnosis and their relevant experiences are essential for providing better care.

Objective

This study aimed to examine the attitude, understanding, and interpretation of a positive diagnosis of HIV.

Methods

The present qualitative study was based on the descriptive phenomenological method. Participants included 13 HIV-positive patients who had been referred to the Kermanshah Counseling Center for Behavioral Diseases in Iran and diagnosed at most 6 months before being interviewed. The data were collected via semi-structured in-depth interviews.

Results

The continuous analyses of the data and the interview notes resulted in the identification of five main themes: contagious disease with two subthemes Illness and Harm to others, new self with a Crisis of identity subtheme, disappointment with the life ending and impending death subtheme, unmentionable disease with two subthemes secretive and horrifying diseases, and loss with Frustration subtheme.

Conclusion

Because the attitudes and behaviors of other people, such as relatives and people in society had a negative impact on the participants' mental status, as well as on their perceptions and understanding about the positive diagnosis, the focus of care for people with HIV/AIDS should shift from therapeutic issues to socio-cultural ones. These issues play a major role in forming an individual's understanding of HIV and can be a vital factor in improving their activities and adaptations to a positive diagnosis.

Adherence to Antiretroviral Therapy Among Incarcerated Persons with HIV: Associations with Methadone and Perceived Safety

With adequate support, people with HIV (PWH) may achieve high levels of adherence to antiretroviral therapy (ART) during incarceration. We examined factors associated with ART utilization and adherence among incarcerated PWH (N = 150) in Indonesia. ART utilization was positively associated with HIV status disclosure (adjusted odds ratio [aOR] = 5.5, 95% CI 1.2-24.1, p = 0.023), drug dependency (aOR = 3.9, 95% CI 1.2-12.6, p = 0.022), health service satisfaction (aOR = 3.2, 95% CI 1.7-6.2, p < 0.001), and perceived need for medical treatment (aOR = 1.6, 95% CI 1.1-2.5, p = 0.011), and negatively associated with chance locus of control (aOR = 0.3, 95% CI 0.1-0.7, p = 0.013). Most participants utilizing ART (74.5%) reported less than "perfect" ART adherence. ART adherence was independently associated with perceived personal safety (β = 0.21, 95% CI 0.01-0.40, p = 0.032) and methadone utilization (β = 0.84, 95% CI 0.10-1.67, p = 0.047). PWH receiving methadone had a sixfold higher adjusted odds of being highly-adherent to ART (aOR = 6.3, 95% CI 1.1-35.7, p = 0.036). Interventions that increase methadone utilization and personal safety may improve ART adherence among incarcerated PWH.

HIV Prevalence and Correlations in Prisons in Different Regions of the World: A Review Article

The prevalence of HIV is substantially higher among prisoners than the general population, while the incidence varies considerably in different regions around the world. If we consider Sub-Saharan Africa as one region with the highest prevalence of HIV, data on African prisoners would be limited. Despite the low prevalence of HIV in the Middle East and North Africa, its incidence is rising in these regions with a few exceptions; there are insufficient data on HIV prevalence in prisons. A similar situation is present in both Pacific and Central Asia as well as in Eastern Europe. A high rate of infection is mainly observed among prisoners in Western and Central parts of Europe, since the data from these are more available than other parts. Nowadays, the sexual transmission mode and tattooing are important ways in HIV risks among prisoners after injecting drug use as the most common route of HIV transmission in all regions. However, it is difficult to compare and analyze the prevalence of HIV among prisoners in different regions regarding the limited data and different methods which they used in collecting data. Eventually, it can certainly be said that prisons are one of the high-risk places for HIV transmission; on the other hand, can be a suitable place for implementing HIV case-finding, linkage to treatment and harm reduction programs.