Barriers and facilitators to linkage to ART in primary care: a qualitative study of patients and providers in Blantyre, Malawi

Post-intervention perceptions on the antiretroviral therapy community group model in Trans Nzoia County, Kenya

Introduction

the increasing number of people receiving antiretroviral therapy (ART) in sub-Saharan Africa has stressed already overburdened health systems. A care model utilizing community-based peer-groups (ART Co-ops) facilitated by community health workers (CHW) was implemented (2016-2018) to address these challenges. In 2018, a post-intervention study assessed perceptions of the intervention.

Methods

forty participants were engaged in focus group discussions consisting of ART Co-op clients, study staff, and health care providers from Kitale HIV clinic. Data were analyzed thematically for content on the intervention, challenges, and recommendations for improvement.

Results

all participants liked the intervention. However, some reported traveling long distances to attend ART Co-op meetings and experiencing stigma with ART Co-ops participation. The ART Co-op inclusion criteria were considered appropriate; however, additional outreach to deliberately include spouses living with HIV, the disabled, the poor, and HIV pregnant women was recommended. Participants liked CHW-directed quarterly group meetings which included ART distribution, adherence review, and illness identification. The inability of the CHW to provide full clinical care, inconvenient meeting venues, poor timekeeping, and non-attendance behaviors were noted as issues. Participants indicated that program continuation, regular CHW training, rotating meetings at group members´ homes, training ART Co-ops leaders to assume CHW tasks, use of pill diaries to check adherence, nutritional support, and economically empowering members through income generation projects would be beneficial.

Conclusion

the intervention was viewed positively by both clinic staff and clients. They identified specific challenges and generated actionable key considerations to improve access and acceptability of the community-based model of care.

Treatment Outcomes After Offering Same-Day Initiation of Human Immunodeficiency Virus Treatment-How to Interpret Discrepancies Between Different Studies

The World Health Organization recommends same-day initiation of antiretroviral therapy (ART) for all persons diagnosed with HIV and ready to start treatment. Evidence, mainly from randomized trials, indicates offering same-day ART increases engagement in care and viral suppression during the first year. In contrast, most observational studies using routine data find same-day ART to be associated with lower engagement in care. We argue that this discrepancy is mainly driven by different time points of enrollment, leading to different denominators. While randomized trials enroll individuals when tested positive, most observational studies start at the time point when ART is initiated. Thus, most observational studies omit those who are lost between diagnosis and treatment, thereby introducing a selection bias in the group with delayed ART. This viewpoint article summarizes the available evidence and argues that the benefits of same-day ART outweigh a potential higher risk of attrition from care after ART initiation.

"There Are Just Too Many Rooms Here!" Perception of Clients and Health Care Workers on the Implementation of Test and Treat Strategy at Area 25 Health Center in Lilongwe, Malawi

Background: Malawi adopted World Health Organisation test-and-treat policy in 2016. The policy initiates early antiretroviral treatment to all clients diagnosed with HIV, irrespective of their CD4 count. However, some facilities record low linkage following the strategy. Perceptions of clients and health care workers on the implementation of test-and-treat strategy were explored in Malawi. Methods: A descriptive qualitative approach was conducted in which 21 in-depth interviews, 9 key informant interviews, and 15 non-participatory observations were conducted. Data were analyzed following thematic approach. Results: Most participants had positive perceptions of the test-and-treat strategy. However, negative perceptions stemmed from the fragmented structure of the facility with multiple rooms in which the client navigates through as well as limited privacy. Conclusion: Optimal implementation of the test-and-treat strategy will need to strengthen privacy and minimize unintended disclosure that is inherent in the organization of services.

Hearing From Men Living With HIV: Experiences With HIV Testing, Treatment, and Viral Load Suppression in Four High-Prevalence Countries in Sub-Saharan Africa

Engaging men in HIV services remains a challenge across sub-Saharan Africa. There is a critical need to better understand facilitators of men's successful engagement with HIV services and assess if there are similarities across contexts. We conducted in-depth interviews and focus group discussions with 92 men living with HIV (MLHIV) across Malawi, Uganda, South Africa, and Eswatini, most of whom had been diagnosed with HIV within the last 5 years. We coded interviews for themes using a constant-comparative approach. We contextualized our findings within a socioecological framework. HIV testing was primarily motivated by illness (individual level), though illness was sometimes accompanied by prompting and support from healthcare providers and/or intimate partners. Once diagnosed, nearly all participants reported immediate linkage to care, initiation of antiretroviral therapy (ART), and subsequent ART adherence. ART initiation and adherence were facilitated by men's sense of agency and ownership over their health (individual level), social support from intimate partners, friends, and family (interpersonal/network level), supportive-directive counseling from healthcare providers (institutional/health systems level), and male-friendly services, i.e., rapid, respectful, private (institutional/health systems level). Health literacy regarding viral suppression (individual level), strengthened by patient-provider communication (institutional/health systems level), was highest in Uganda, where most men could discuss viral load testing experiences, report their viral load status (most reported suppressed), and demonstrate an understanding of treatment as prevention. Elsewhere, few participants understood what viral load suppression was and even fewer knew their viral load status. Our findings reveal socioecological-level facilitators of men's progress across the HIV-care continuum. Programs may want to leverage facilitators of ART initiation and adherence that span socioecological levels—e.g., healthcare ownership and agency, social support, supportive-directive counseling—and apply them to each end of the continuum to encourage early HIV testing/diagnosis and improve health literacy to help men understand and achieve viral load suppression.

"You have a self-testing method that preserves privacy so how come you cannot give us treatment that does too?" Exploring the reasoning among young people about linkage to prevention, care and treatment after HIV self-testing in Southern Malawi

BACKGROUND

Young people, aged 16-24, in southern Malawi have high uptake of HIV self-testing (HIVST) but low rates of linking to services following HIVST, especially in comparison, to older generations. The study aim is to explore the barriers and facilitators to linkage for HIV prevention and care following uptake of HIV self-testing among young Malawians.

METHODS

We used qualitative methods. Young people aged 16-24 who had received HIVST; community-based distribution agents (CBDAs) and health care workers from the linked facilities were purposively sampled from two villages in rural southern Malawi.

RESULTS

We conducted in-depth interviews with thirteen young people (9 female) and held four focus groups with 28 healthcare workers and CBDAs. Young people strongly felt the social consequences associated with inadvertent disclosure of HIV sero-status were a significant deterrent to linkage at their stage in life. They also felt communication on testing benefits and the referral process after testing was poor. In contrast, they valued encouragement from those they trusted, other's positive treatment experiences and having a "strength of mind". CBDAs were important facilitators for young people as they are able to foster a trusting relationship and had more understanding of the factors which prevented young people from linking following HIVST than the healthcare workers. Young people noted contextual barriers to linkage, for example, being seen on the road to the healthcare centre, but also societal gendered barriers. For example, young females and younger adolescents were less likely to have the financial independence to link to services whilst young males (aged 19-24) had the finances but lacked a supportive network to encourage linkage following testing. Overall, it was felt that the primary "responsibility" for linking to formal healthcare following self-testing is shouldered by the young person and not the healthcare system.

CONCLUSIONS

Young people are happy to self-test for HIV but faced barriers to link to services following a self-test. Potential interventions for improving linkage suggested by this analysis include the establishment of youth-friendly linkage services, enhanced lines of communication between young people and healthcare providers and prioritising linkage for future interventions when targeting young people following HIVST.

Perspectives on linkage to care for patients diagnosed with HIV: A qualitative study at a rural health center in South Western Uganda

Linkage to care for newly diagnosed human immunodeficiency virus (HIV) patients is important to ensure that patients have good access to care. However, there is little information about factors influencing linkage to care for HIV patients. We aimed to identify existing measures in place that promote linkage to care and to explore facilitators and barriers to linkage to care for clients diagnosed with HIV/acquired immune deficiency syndrome at a rural health center in Uganda. This descriptive qualitative study enrolled 33 purposively selected participants who included expert clients, linkage facilitators, heads of families with people living with HIV, and health workers. Data were collected using in-depth interviews that were audio-recorded, transcribed, and translated. The data were manually analyzed to generate themes. The following four themes were generated: 1) availability of services that include counseling, testing, treatment, follow-up, referral, outreach activities, and support systems. 2) Barriers to linkage to care were at the individual, health facility, and community levels. Individual-level barriers were socioeconomic status, high transport costs, fear of adverse drug effects, fear of broken relationships, and denial of positive results or treatment, while health facility barriers were reported to be long waiting time, negative staff attitude, and drug stock outs. Community barriers were mostly due to stigma experienced by HIV clients, resulting in discrimination by community members. 3) Facilitators to linkage to care were positive staff attitudes, access to information, fear of death, and support from others. 4) Suggestions for improving service delivery were shortening waiting time, integrating HIV services, increasing staff numbers, and intensifying outreaches. Our findings highlight the importance of stakeholder involvement in linkage to care. Access and linkage to care are positively and negatively influenced at the individual, community, and health facility levels. However, integration of HIV services and intensifying outreaches are key to improving linkage to care.

Evaluation of the integration of telehealth into the same-day antiretroviral therapy initiation service in Bangkok, Thailand in response to COVID-19: a mixed-method analysis of real-world data

Introduction

Same‐day antiretroviral therapy (SDART) initiation has been implemented at the Thai Red Cross Anonymous Clinic (TRCAC) in Bangkok, Thailand, since 2017. HIV‐positive, antiretroviral therapy (ART)‐naïve clients who are willing and clinically eligible start ART on the day of HIV diagnosis. In response to the first wave of the coronavirus disease 2019 (COVID‐19) outbreak in March 2020, telehealth follow‐up was established to comply with COVID‐19 preventive measures and allow service continuation. Here, we evaluate its implementation.

Methods

Pre‐COVID‐19 (until February 2020) clients who initiated SDART received a 2‐week ART supply and returned to the clinic for evaluation before being referred to long‐term ART maintenance facilities. If no adverse events (AEs) occurred, another 8‐week ART supply was provided while referral was arranged. During the first wave of COVID‐19 (March–May 2020), clients received a 4‐week ART supply and the option of conducting follow‐up consultation and physical examination via video call. Clients with severe AEs were required to return to TRCAC; those without received another 6‐week ART supply by courier to bridge transition to long‐term facilities. This adaptation continued post‐first wave (May–August 2020). Routine service data were analysed using data from March to August 2019 for the pre‐COVID‐19 period. Interviews and thematic analysis were conducted to understand experiences of clients and providers, and gain feedback for service improvement.

Results

Of 922, 183 and 321 eligible clients from the three periods, SDART reach [89.9%, 96.2% and 92.2% (p = 0.018)] and ART initiation rates [88.1%, 90.9% and 94.9% (p<0.001)] were high. ART uptake, time to ART initiation and rates of follow‐up completion improved over time. After the integration, 35.3% received the telehealth follow‐up. The rates of successful referral to a long‐term facility (91.8% vs. 95.3%, p = 0.535) and retention in care at months 3 (97.5% vs. 98.0%, p = 0.963) and 6 (94.1% vs. 98.4%, p = 0.148) were comparable for those receiving in‐person and telehealth follow‐up. Six clients and nine providers were interviewed; six themes on service experience and feedback were identified.

Conclusions

Telehealth follow‐up with ART delivery for SDART clients is a feasible option to differentiate ART initiation services at TRCAC, which led to its incorporation into routine service.

Psychosocial interventions for improving engagement in care and health and behavioural outcomes for adolescents and young people living with HIV: a systematic review and meta-analysis

INTRODUCTION

Adolescents and young people comprise a growing proportion of new HIV infections globally, yet current approaches do not effectively engage this group, and adolescent HIV-related outcomes are the poorest among all age groups. Providing psychosocial interventions incorporating psychological, social, and/or behavioural approaches offer a potential pathway to improve engagement in care and health and behavioural outcomes among adolescents and young people living with HIV (AYPLHIV).

METHODS

A systematic search of all peer-reviewed papers published between January 2000 and July 2020 was conducted through four electronic databases (Cochrane Library, PsycINFO, PubMed and Scopus). We included randomized controlled trials evaluating psychosocial interventions aimed at improving engagement in care and health and behavioural outcomes of AYPLHIV aged 10 to 24 years.

RESULTS AND DISCUSSION

Thirty relevant studies were identified. Studies took place in the United States (n = 18, 60%), sub-Saharan Africa (Nigeria, South Africa, Uganda, Zambia, Zimbabwe) and Southeast Asia (Thailand). Outcomes of interest included adherence to antiretroviral therapy (ART), ART knowledge, viral load data, sexual risk behaviours, sexual risk knowledge, retention in care and linkage to care. Overall, psychosocial interventions for AYPLHIV showed important, small-to-moderate effects on adherence to ART (SMD = 0.3907, 95% CI: 0.1059 to 0.6754, 21 studies, n = 2647) and viral load (SMD = -0.2607, 95% CI -04518 to -0.0696, 12 studies, n = 1566). The psychosocial interventions reviewed did not demonstrate significant impacts on retention in care (n = 8), sexual risk behaviours and knowledge (n = 13), viral suppression (n = 4), undetectable viral load (n = 5) or linkage to care (n = 1) among AYPLHIV. No studies measured transition to adult services. Effective interventions employed various approaches, including digital and lay health worker delivery, which hold promise for scaling interventions in the context of COVID-19.

CONCLUSIONS

This review highlights the potential of psychosocial interventions in improving health outcomes in AYPLHIV. However, more research needs to be conducted on interventions that can effectively reduce sexual risk behaviours of AYPLHIV, as well as those that can strengthen engagement in care. Further investment is needed to ensure that these interventions are cost-effective, sustainable and resilient in the face of resource constraints and global challenges such as the COVID-19 pandemic.

Community and health system factors associated with antiretroviral therapy initiation among men and women in Malawi: a mixed methods study exploring gender-specific barriers to care

BACKGROUND

Although community and health system factors are known to be critical to timely antiretroviral therapy (ART) initiation, little is known about how they affect men and women.

METHODS

We examined community- and health system-level factors associated with ART initiation in Malawi and whether associations differ by gender; 312 ART initiates and 108 non-initiates completed a survey; a subset of 30 individuals completed an indepth interview. Quantitative data were analyzed using univariate and multivariate logistic regressions, with separate models by gender. Qualitative data were analyzed through constant comparison methods.

RESULTS

Among women, no community-level characteristics were associated with ART initiation in multivariable models; among men, receiving social support for HIV services (adjusted OR [AOR]=4.61; p<0.05) was associated with ART initiation. Two health system factors were associated with ART initiation among men and one for women: trust that accessing ART services would not lead to unwanted disclosure (women: AOR=4.51, p<0.01; men: AOR=1.71, p<0.01) and trust that clients were not turned away from ART services (men: 12.36, p=0.001).

CONCLUSIONS

Qualitative data indicate that men were concerned about unwanted disclosure due to engaging in ART services and long waiting times for services. Interventions to remove health system barriers to ART services should be explored to promote social support among men.

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.

Barriers and Facilitators of Same-Day Antiretroviral Therapy Initiation Among People Newly Diagnosed with HIV in Ethiopia: Qualitative Study Using the Transtheoretical Model of Behavioral Change

Purpose

HIV test and treat approach is currently a strategy used as a part of the prevention and control program in Ethiopia. The strategy adopts initiating antiretroviral therapy (ART) on the same-day as HIV diagnosis or in the next visit. However, there is little evidence on barriers and facilitators of same-day (ART) initiation in Ethiopia. Therefore, this study aimed to investigate barriers and facilitators of same-day (ART) initiation in the northwest Ethiopia.

Patients and Methods

A qualitative study was conducted in East Gojjam Zone in northwest Ethiopia. Purposively selected HIV patients, healthcare workers, and treatment assistants participated in the qualitative study. Data were collected through in-depth interviews and focus group discussions (FGDs). Coding was done via ATLAS.ti software thematically. The interviews and FGDs were conducted in Amharic (local language) and then transcribed verbatim and translated into English. Coding was done via ATLAS.ti software. The thematic analysis approach was employed using the constructs of the transtheoretical behavioral model (TTM) to show stages of change that newly HIV diagnosed experienced in the course of preparation for treatment initiation.

Results

A total of 19 patients, 12 treatment supporters, and 9 healthcare workers participated in the qualitative study. Shocking due to the test result, having no symptoms, mistrust of the test result, and seeking spiritual healing from holy water were the major barriers to start ART in the same-day of diagnosis or within the next visit.

Conclusion

During HIV diagnosis, more barriers were observed in the early stages, while treatment facilitators emerged in the later stages of TTM. The TTM model can be applied to characterize where participants were in the stages of change.

Same-day antiretroviral treatment (ART) initiation and associated factors among HIV positive people in Northwest Ethiopia: baseline characteristics of prospective cohort

Background

Despite a well-established fact that same-day or rapid ART initiation after a positive HIV test result is vital for faster viral suppression and for prevention of further sexual transmissions of HIV, there is a paucity of evidence on the uptake of same-day ART initiation among newly HIV diagnosed people in Northwest, Ethiopia.

Methods

A cross-sectional study was conducted between December 1st, 2018 and July 30, 2019. About 759 newly HIV diagnosed adults were recruited from 24 health facilities. Data were collected using interviewer-administered questionnaire. Data were entered using EPI-Data and exported to SPSS and STATA software for further analysis. Bivariate logistic regression was used to select candidate variables at p-value less than 0.25 for multivariate logistic regression. Then adjusted odds ratio with 95% Confidence Interval (CI) at p-value of less than 0.05 was used to declare the statistical associations between the dependent and independent variables.

Result

Magnitude of same-day ART initiation was 318 (41.90%) [(95% CI, 38.2–45.20%)]. Factors associated with same-day ART initiation were: Patients resided in West Gojjam Zone were 2.04 times more likely to initiate same-day ART compared to those in Bahir Dar city administration [AOR = 2.04 (1.04–3.97)], patients in the health centers were 3.06 times more likely to initiate same-day ART initiation compared to those in the hospitals [AOR = 3.06 (1.90–4.92)] and Patients who were diagnosed their HIV status at the same health facility where they linked for ART were 2.16 times more likely to initiate ART at the same-day of diagnosis [AOR = 2.16 (91.24–3.74)]. Moreover, patients with no opportunistic infection [AOR = 2.08 (1.04–4.19)] and pregnant women [AOR = 3.97 (1.78–8.87)] were more likely to initiate ART same-day of diagnosis.

Conclusions

Same-day ART initiation was low among HIV patients in Ethiopia. Patients attending their treatment at hospitals and those from big city (Bahir Dar) were less likely to initiate same-day ART. Clinical factors such as having opportunistic infections and non-pregnancy status affected the immediate initiation of treatment. HIV positive people who seek care in hospitals and those tested HIV positive from another health facilities in which they did not intend to continue their ART follow-up care need special attention.

Predictors of First-Time and Repeat HIV Testing Among HIV-Positive Individuals in Kenya

BACKGROUND

Despite a doubling of HIV testing coverage in Kenya over the past decade, approximately 2 in 10 people with HIV remained unaware of their infection in 2018. HIV testing is most effective in identifying people with undiagnosed HIV through frequent and strategic testing in populations at high risk. An assessment of testing frequency and predictors of first-time and repeat testing is critical for monitoring effectiveness of testing strategies.

METHODS

We conducted a cross-sectional analysis of adults aged ≥18 years who tested HIV-positive at 4 HIV testing and counseling clinics in Kenya from February 2015 to February 2016. We categorized individuals based on testing history, used Wilcoxon rank-sum tests to assess differences in intervals between the most recent and current HIV test, and used log-binomial regression to determine characteristics associated with first-time and repeat testing.

RESULTS

Among 1136 people testing HIV-positive, 336 (30%) had never tested before and 800 (70%) had, of whom 208 (26%) had previously tested positive. Among previously negative repeat testers, the median intertest interval was 414 days in key/priority populations (interquartile range = 179-1072) vs. 538 in the general population (interquartile range = 228-1299) (P = 0.09). Compared with previously negative repeat testers, being a first-time tester was associated with being age ≥40 years [vs. 18-24; adjusted risk ratio = 1.67, 95% confidence interval (CI): 1.23 to 2.26], men (vs. women; adjusted risk ratio = 1.45, 95% CI: 1.21 to 1.71), and testing through provider-initiated testing and counseling (vs. client initiated; 1.19, 95% CI: 1.00 to 1.40).

CONCLUSIONS

There is a need to increase HIV testing among older individuals and men, increase testing frequency in key/priority populations, and maintain provider-initiated and facility-based testing to reach first-time testers.

Optimizing Test and Treat in Malawi: health care worker perspectives on barriers and facilitators to ART initiation among HIV-infected clients who feel healthy

Background: Test and Treat has been widely adopted throughout sub-Saharan Africa, whereby all HIV-positive individuals initiate antiretroviral therapy (ART) immediately upon diagnosis and continue for life. However, clients who feel healthy may delay ART initiation, despite being eligible under new treatment guidelines.

Objective: We examined health care worker (HCW) perceptions and experiences on how feeling healthy positively or negatively influences treatment initiation among HIV-positive clients in Malawi.

Methods: We conducted 12 focus group discussions with 101 HCWs across six health facilities in Central Malawi. Data were analyzed through constant comparison methods using Atlas.ti7.5.

Results: Feeling healthy influences perceptions of ART initiation among HIV-positive clients. HCWs described that healthy clients feel that there are few tangible benefits to immediate ART initiation, but numerous risks. Fear of stigma and unwanted disclosure, disruption of daily activities, fear of side effects, and limited knowledge about the benefits of early initiation were perceived by HCWs to deter healthy clients from initiating ART.

Conclusion: Feeling healthy may exacerbate barriers to ART initiation. Strategies to reach healthy clients are needed, such as chronic care models, differentiated models of care that minimize disruptions to daily activities, and community sensitization on the benefits of early initiation.

Provider-initiated HIV testing and TB screening in the era of universal coverage: Are the right people being reached? A cohort study in Blantyre, Malawi

INTRODUCTION

Patients with tuberculosis (TB) symptoms have high prevalence of HIV, and should be prioritised for HIV testing.

METHODS

In a prospective cohort study in Bangwe primary care clinic, Blantyre, Malawi, all adults (18 years or older) presenting with an acute illness were screened for TB symptoms (cough, fever, night sweats, weight loss). Demographic characteristics were linked to exit interview by fingerprint bioidentification. Multivariable logistic regression models were constructed to estimate the proportion completing same-visit HIV testing, comparing between those with and without TB symptoms.

RESULTS

There were 5427 adult attendees between 21/5/2018 and 6/9/2018. Exit interviews were performed for 2402 (44%). 276 patients were excluded from the analysis, being already on antiretroviral therapy (ART). Presentation with any TB symptom was common for men (54.6%) and women (57.4%). Overall 27.6% (585/ 2121) attenders reported being offered testing and 21.5% (455/2121) completed provider-initiated HIV testing and counselling (PITC) and received results. The proportions offered testing were similar among participants with and without TB symptoms (any TB symptom: 29.0% vs. 25.7%). This was consistent for each individual symptom; cough, weight loss, fever and night sweats. Multivariable regression models indicated men, younger adults and participants who had previously tested were more likely to complete PITC than women, older adults and those who had never previously tested.

CONCLUSIONS

Same-visit completion of HIV testing was suboptimal, especially among groups known to have high prevalence of undiagnosed HIV. As countries approach universal coverage of ART, identifying and prioritising currently underserved groups for HIV testing will be essential.

Secrets and Silence: Agency of Young Women Managing HIV Disclosure

Drawing on a 12-month ethnography with young women living with HIV in Zambia, we explore their everyday strategies to avoid unintentional disclosure of their HIV status. Young women practiced secrecy with sexual partners, through hiding their antiretroviral therapy and using veiled language around HIV. Whilst remaining silent about their HIV status enabled them to maintain identities beyond HIV, this secrecy triggered feelings of guilt and anxiety, suggesting that their agency was "bounded" by the context of persistent stigma. These strategies to hide their HIV status question public health narratives urging disclosure, and support disclosure-counseling approaches that champions choice.

The state of the evidence for voluntary home-based human immunodeficiency virus counseling and testing in the community: A proposed model for evidence translation

BACKGROUND

Home-based voluntary human immunodeficiency virus (HIV) counseling and testing (HBVCT) plays a significant role in reducing HIV-related risk-taking behaviors. Adopting evidence-based interventions is essential, but few conceptual models exist to guide the development, implementation, and evaluation of these interventions.

AIMS

Our proposed model for evidence translation based on evidence review describes the implementation process of HBVCT in the community.

MATERIALS AND METHODS

Our study adopted the translating research into practice model, which incorporates information needs about the implementation, planning, and execution required for consideration by clinicians. Thirteen systematic reviews published in the English language from January 1, 2000 to February 9, 2020 were retrieved and reviewed from four electronic databases and journals, including EMBASE, PubMed, JBI Database of Systematic Reviews and Implementation Reports, and Cochrane Library.

RESULTS

The analysis of the review papers based on the phenomenon of interest, results, and the population revealed some distinctions in the number of socioecological levels used by this evidence synthesis. These levels of factors include individual, interpersonal, organizational, community, and public policies. HBVCT is an essential component of HIV prevention programs and a critical entry point for adequate care and treatment.

DISCUSSION

This collaborative model demonstrates the application of research to a real-world health care setting.

A Qualitative Assessment of Provider and Client Experiences With 3- and 6-Month Dispensing Intervals of Antiretroviral Therapy in Malawi

INTRODUCTION

Multimonth dispensing (MMD) of antiretroviral therapy (ART) is a differentiated model of care that can help overcome health system challenges and reduce the burden of HIV care on clients. Although 3-month dispensing has been the standard of care, interest has increased in extending refill intervals to 6 months. We explored client and provider experiences with MMD in Malawi as part of a cluster randomized trial evaluating 3- versus 6-month ART dispensing.

METHODS

Semi-structured in-depth interviews were conducted with 17 ART providers and 62 stable, adult clients with HIV on ART. Clients and providers were evenly divided by arm and were eligible for an interview if they had been participating in the study for 1 year (clients) or 6 months (providers). Questions focused on perceived challenges and benefits of the 3- or 6-month amount of ART dispensing. Interviews were transcribed, and data were coded and analyzed using constant comparison.

RESULTS

Both clients and providers reported that the larger medication supply had benefits. Clients reported decreased costs due to less frequent travel to the clinic and increased time for income-generating activities. Clients in the 6-month dispensing arm reported a greater sense of personal freedom and normalcy. Providers felt that the 6-month dispensing interval reduced their workload. They also expressed concerned about clients' challenges with ART storage at home, but clients reported no storage problems. Although providers mentioned the potential risk of clients sharing the larger medication supply with family or friends, clients emphasized the value of ART and reported only rare, short-term sharing, mostly with their spouses. Providers mentioned clients' lack of motivation to seek care for illnesses that might occur between refill appointments.

CONCLUSIONS

The 6-month ART dispensing arm was particularly beneficial to clients for decreased costs, increased time for income generation, and a greater sense of normalcy. Providers' concerns about storage, sharing, and return visits to the facility did not emerge in client interviews. Further data are needed on the feasibility of implementing a large-scale program with 6-month dispensing.

Same-day antiretroviral therapy initiation for HIV-infected adults in South Africa: Analysis of routine data

Same-day initiation (SDI) of antiretroviral therapy (ART) has been recommended to improve ART programme outcomes in South Africa since August 2017. This study assessed implementation of SDI over time in two South African districts, describing the characteristics of same-day initiators and evaluating the impact of SDI on retention in ART care. Routine data were analysed for HIV-infected adults who were newly initiating ART in Johannesburg or Mopani Districts between October 2017 and June 2018. Characteristics of same-day ART initiators were compared to later initiators, and losses to follow-up (LTFU) to six months were assessed using Kaplan Meier survival analysis and multivariate logistic regression. The dataset comprised 32 290 records (29 964 from Johannesburg and 2 326 from Mopani). The overall rate of SDI was 40.4% (n = 13 038), increasing from 30.3% in October 2017 to 54.2% in June 2018. Same-day ART initiators were younger, more likely to be female and presented with less advanced clinical disease than those initiating treatment at later times following diagnosis (p<0.001 for all). SDI was associated with disengagement from care: LTFU was 30.1% in the SDI group compared to 22.4%, 19.8% and 21.9% among clients initiating ART 1–7 days, 8–21 days and ≥22 days after HIV diagnosis, respectively (p<0.001). LTFU was significantly more likely among clients in Johannesburg versus Mopani (adjusted odds ratio (aOR) = 1.43, p<0.001) and among same-day versus later initiators (aOR = 1.45, p<0.001), while increasing age reduced LTFU (aOR = 0.97, p<0.001). In conclusion, SDI has increased over time as per national guidelines, but there is serious concern regarding the reduced rate of retention among same-day initiators. Nevertheless, SDI may result in a net programmatic benefit provided that interventions are implemented to support client readiness for treatment and ongoing engagement in ART care, particularly among younger adults in large ART programmes such as Johannesburg.

Zwakala Ndoda: a cluster and individually randomized trial aimed at improving testing, linkage, and adherence to treatment for hard-to reach men in KwaZulu-Natal, South Africa

BACKGROUND

Men in sub-Saharan Africa are less likely than women to get tested for HIV, less likely to present for treatment, less likely to be maintained in treatment, more likely to have detectable viral load, more likely to transmit HIV with unprotected intercourse, and more likely to progress to AIDS and die sooner from HIV. The ultimate objective of this research is to provide evidence-based strategies to improve HIV testing and treatment of HIV-infected men.

METHODS

This study is being conducted in the Greater Edendale Area and Vulindlela region in KwaZulu-Natal, South Africa. It is a two-stage design of a cluster-randomized trial and an individual randomized trial to test how structural and individual-level interventions address the demand-side factors that affect HIV testing and treatment for hard-to reach, high-risk men. It combines male-focused mobilization, community-based mobile HIV testing services, and a small incentive to determine if the strategies singly and in combination can result in more men diagnosed with HIV, and more men linked to and maintained in care with undetectable viral load.

DISCUSSION

A priority for sub-Sahara Africa is developing and evaluating novel and cost-effective strategies for identifying hard-to-reach groups such as men, linking them to HIV testing and care services, and maintaining them in care to the point of viral suppression. We propose a combination prevention intervention that addresses men's individual, interpersonal, and structural barriers to testing and care. This includes male-led mobilization to encourage uptake of testing and treatment, male-focused testing venues, male-only counselors, developing counseling models that are flexible and responsive to men, and strategies for adhering to clinic visits without missing work and navigating the healthcare system. By thoughtfully combining male-focused mobilization, and testing and addressing some of the barriers to male engagement with health facilities, this study hopes to add to the growing evidence base about how to reach, test, link, and maintain a hard-to-reach group such as men in HIV treatment and care services.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03794245. Registered on 4 January 2019.

Findings from home-based HIV testing and facilitated linkage after scale-up of test and treat in rural South Africa: young people still missing

OBJECTIVES

The aim of the study was to estimate rates of linkage to HIV care and antiretroviral treatment (ART) initiation after the introduction of home-based HIV counselling and testing (HBHCT) and telephone-facilitated support for linkage in rural South Africa.

METHODS

A population-based prospective cohort study was carried out in KwaZulu Natal, South Africa. All residents aged ≥ 15 years were eligible for HBHCT. Those who tested positive and were not in care were referred for ART at one of 11 public-sector clinics. Individuals who did not attend the clinic within 2 weeks were sent a short message service (SMS) reminder; those who had not attended after a further 2 weeks were telephoned by a nurse counsellor, to discuss concerns and encourage linkage. Kaplan-Meier methods were used to estimate the proportion of newly diagnosed individuals linking to care and initiating ART.

RESULTS

Among 38 827 individuals visited, 26% accepted HBHCT. Uptake was higher in women than in men (30% versus 20%, respectively), but similar in people aged < 30 years and ≥ 30 years (28% versus 26%, respectively). A total of 784 (8%) tested HIV positive, of whom 427 (54%) were newly diagnosed. Within 6 months, 31% of women and 18% of men < 30 years old had linked to care, and 29% and 16%, respectively, had started ART. Among those ≥ 30 years, 41% of women and 38% of men had linked to care within 6 months, and 41% and 35%, respectively, had started ART.

CONCLUSIONS

Despite facilitated linkage, rates of timely linkage to care and ART initiation after HBHCT were very low, particularly among young men. Innovations are needed to provide effective HIV care and prevention interventions to young people, and thus maximize the benefits of universal test and treat.

Barriers and facilitators to linkage to care and ART initiation in the setting of high ART coverage in Botswana

We conducted a qualitative study using focus groups and in-depth interviews to explore barriers to and facilitators of linkage-to-care and antiretroviral treatment (ART) initiation in Botswana. Participants were selected from communities receiving interventions through the Ya Tsie Study. Fifteen healthcare providers and 49 HIV-positive individuals participated. HIV-positive participants identified barriers including stigma, discrimination and overcrowded clinics, and negative staff attitudes; personal factors, such as a lack of acceptance of one's HIV status, non-disclosure, and gender differences; along with lack of social/family support, and certain religious beliefs. Healthcare providers cited delayed test results, poverty, and transport difficulties as additional barriers. Major facilitators were support from healthcare providers, including home visits, social support, and knowing the benefits of ART. Participants were highly supportive of universal ART as a personal health measure. Our results highlighted a persistent structural health facility barrier: HIV-positive patients expressed strong discontent with HIV care/treatment being delivered differently than routine healthcare, feeling inconvenienced and stigmatized by separately designated locations and days of service. This barrier was particularly problematic for highly mobile persons. Addressing this structural barrier, which persists even in the context of high ART uptake, could bring gains in willingness to initiate ART and improved adherence in Botswana and elsewhere.

Challenges with seeking HIV care services: perspectives of older adults infected with HIV in western Kenya

BACKGROUND

While younger adults (15-49 years) form the majority of the population living with HIV, older adults (≥50 years) infected with HIV face multiple challenges related to the aging process and HIV. We explored the experiences of older persons infected with HIV at the Academic Model Providing Access to Healthcare (AMPATH) program in western Kenya to understand the challenges faced when seeking HIV care services.

METHODS

Between November 2016 and April 2017, a total of 57 adults aged 50 years and above were recruited from two AMPATH facilities - one rural and one urban facility. A total of 25 in-depth interviews and four focus group discussions were conducted, audio-recorded, transcribed and thematic analysis performed.

RESULTS

Study participants raised unique challenges with seeking HIV care that include visits to multiple healthcare providers to manage HIV and comorbidities and as a result impact on their adherence to medication and clinical visits. Challenges with inadequate quality of facilities and poor patient-provider communication were also raised. Participants' preference for matched gender and older age for care providers that serve older patients were identified.

CONCLUSION

Results indicate multiple challenges faced by older adults that need attention in ensuring continuous engagement in HIV care. Targeted HIV care for older adults would, therefore, significantly improve their access to and experience of HIV care. Of key importance is the integration of other chronic diseases into HIV care and employing staff that matches the needs of older adults.

Performance and workflow assessment of six nucleic acid extraction technologies for use in resource limited settings

Infectious disease nucleic acid amplification technologies (NAAT) have superior sensitivity, specificity, and rapid time to result compared to traditional microbiological methods. Recovery of concentrated, high quality pathogen nucleic acid (NA) from complex specimen matrices is required for optimal performance of several NA amplification/detection technologies such as polymerase chain reaction (PCR). Fully integrated NAAT platforms that enable rapid sample-to-result workflows with minimal user input are generally restricted to larger reference lab settings, and their complexity and cost are prohibitive to widespread implementation in resource limited settings (RLS). Identification of component technologies for incorporation of reliable and affordable sample preparation with pathogen NA amplification/detection into an integrated platform suitable for RLS, is a necessary first step toward achieving the overarching goal of reducing infectious disease-associated morbidity and mortality globally. In the current study, we evaluate the performance of six novel NA extraction technologies from different developers using blinded panels of stool, sputum and blood spiked with variable amounts of quality-controlled DNA- and/or RNA-based microbes. The extraction efficiencies were semi-quantitatively assessed using validated real-time reverse transcription (RT)-PCR assays specific for each microbe and comparing target-specific RT-PCR results to those obtained with reference NA extraction methods. The technologies were ranked based on overall diagnostic accuracy (analytical sensitivity and specificity). Sample input and output volumes, total processing time, user-required manual steps and cost estimates were also examined for suitability in RLS. Together with the performance analysis, these metrics were used to select the more suitable candidate technologies for further optimization of integrated NA amplification and detection technologies for RLS.

Understanding factors influencing linkage to HIV care in a rural setting, Mbeya, Tanzania: qualitative findings of a mixed methods study

BACKGROUND

In remote rural Tanzania, the rate of linkage into HIV care was estimated at 28% in 2014. This study explored facilitators and barriers to linkage to HIV care at individual/patient, health care provider, health system, and contextual levels to inform eventual design of interventions to improve linkage to HIV care.

METHODS

We conducted a descriptive qualitative study nested in a cohort study of 1012 newly diagnosed HIV-positive individuals in Mbeya region between August 2014 and July 2015. We conducted 8 focus group discussions and 10 in-depth interviews with recently diagnosed HIV-positive individuals and 20 individual interviews with healthcare providers. Transcripts were analyzed inductively using thematic content analysis. The emergent themes were then deductively fitted into the four level ecological model.

RESULTS

We identified multiple factors influencing linkage to care. HIV status disclosure, support from family/relatives and having symptoms of disease were reported to facilitate linkage at the individual level. Fear of stigma, lack of disclosure, denial and being asymptomatic, belief in witchcraft and spiritual beliefs were barriers identified at individual's level. At providers' level; support and good patient-staff relationship facilitated linkage, while negative attitudes and abusive language were reported barriers to successful linkage. Clear referral procedures and well-organized clinic procedures were system-level facilitators, whereas poorly organized clinic procedures and visit schedules, overcrowding, long waiting times and lack of resources were reported barriers. Distance and transport costs to HIV care centers were important contextual factors influencing linkage to care.

CONCLUSION

Linkage to HIV care is an important step towards proper management of HIV. We found that access and linkage to care are influenced positively and negatively at all levels, however, the individual-level and health system-level factors were most prominent in this setting. Interventions must address issues around stigma, denial and inadequate awareness of the value of early linkage to care, and improve the capacity of HIV treatment/care clinics to implement quality care, particularly in light of adopting the 'Test and Treat' model of HIV treatment and care recommended by the World Health Organization.

"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.

Design and protocol for a pragmatic randomised study to optimise screening, prevention and care for tuberculosis and HIV in Malawi (PROSPECT Study)

Background: Adults seeking diagnosis and treatment for tuberculosis (TB) and HIV in low-resource settings face considerable barriers and have high pre-treatment mortality. Efforts to improve access to prompt TB treatment have been hampered by limitations in TB diagnostics, with considerable uncertainty about how available and new tests can best be implemented. Design and methods: The PROSPECT Study is an open, three-arm pragmatic randomised study that will investigate the effectiveness and cost-effectiveness of optimised HIV and TB diagnosis and linkage to care interventions in reducing time to TB diagnosis and prevalence of undiagnosed TB and HIV in primary care in Blantyre, Malawi. Participants (≥ 18 years) attending a primary care clinic with TB symptoms (cough of any duration) will be randomly allocated to one of three groups: (i) standard of care; (ii) optimised HIV diagnosis and linkage; or (iii) optimised HIV and TB diagnosis and linkage. We will test two hypotheses: firstly, whether prompt linkage to HIV care should be prioritised for adults with TB symptoms; and secondly, whether an optimised TB triage testing algorithm comprised of digital chest x-ray evaluated by computer-aided diagnosis software and sputum GeneXpert MTB/Rif can outperform clinician-directed TB screening. The primary trial outcome will be time to TB treatment initiation by day 56, and secondary outcomes will include prevalence of undiagnosed TB and HIV, mortality, quality of life, and cost-effectiveness. Conclusions: The PROSPECT Study will provide urgently-needed evidence under "real-life" conditions to inform clinicians and policy makers on how best to improve TB/HIV diagnosis and treatment in Africa. Clinical trial registration: NCT03519425 (08/05/2018).

Why do people living with HIV not initiate treatment? A systematic review of qualitative evidence from low- and middle-income countries

BACKGROUND

Many people living with HIV (PLWH) who are eligible for antiretroviral therapy (ART) do not initiate treatment, leading to excess morbidity, mortality, and viral transmission. As countries move to treat all PLWH at diagnosis, it is critical to understand reasons for non-initiation.

METHODS

We conducted a systematic review of the qualitative literature on reasons for ART non-initiation in low- and middle-income countries. We screened 1376 titles, 680 abstracts, and 154 full-text reports of English-language qualitative studies published January 2000-April 2017; 20 met criteria for inclusion. Our analysis involved three steps. First, we used a "thematic synthesis" approach, identifying supply-side (facility) and demand-side (patient) factors commonly cited across different studies and organizing these factors into themes. Second, we conducted a theoretical mapping exercise, developing an explanatory model for patients' decision-making process to start (or not to start) ART, based on inductive analysis of evidence reviewed. Third, we used this explanatory model to identify opportunities to intervene to increase ART uptake.

RESULTS

Demand-side factors implicated in decisions not to start ART included feeling healthy, low social support, gender norms, HIV stigma, and difficulties translating intentions into actions. Supply-side factors included high care-seeking costs, concerns about confidentiality, low-quality health services, recommended lifestyle changes, and incomplete knowledge of treatment benefits. Developing an explanatory model, which we labeled the Transdisciplinary Model of Health Decision-Making, we posited that contextual factors determine the costs and benefits of ART; patients perceive this context (through cognitive and emotional appraisals) and form an intention whether or not to start; and these intentions may (or may not) be translated into actions. Interventions can target each of these three stages.

CONCLUSIONS

Reasons for not starting ART included consistent themes across studies. Future interventions could: (1) provide information on the large health and prevention benefits of ART and the low side effects of current regimens; (2) reduce stigma at the patient and community levels and increase confidentiality where stigma persists; (3) remove lifestyle requirements and support patients in integrating ART into their lives; and (4) alleviate economic burdens of ART. Interventions addressing reasons for non-initiation will be critical to the success of HIV "treat all" strategies.

Exploring Treatment Needs and Expectations for People Living with HIV in South Africa: A Qualitative Study

The UNAIDS 90-90-90 treatment targets aim to dramatically increase the number of people who initiate antiretroviral therapy (ART) by 2020. Greater understanding of barriers to ART initiation in high prevalence countries like South Africa is critical. Qualitative semi-structured interviews were conducted with 30 participants in Gugulethu Township, South Africa, including 10 healthcare providers and 20 people living with HIV (PLWH) who did not initiate ART. Interviews explored barriers to ART initiation and acceptability of theory-based intervention strategies to optimize ART initiation. An inductive content analytic approach was applied to the data. Consistent with the Theory of Triadic Influence, barriers to ART initiation were identified at the individual, social, and structural levels. Results suggested high acceptability for intervention strategies involving trained HIV-positive peers among South African PLWH and healthcare providers. Research is needed to evaluate their feasibility and efficacy in high HIV prevalence countries.

Design and protocol for a pragmatic randomised study to optimise screening, prevention and care for tuberculosis and HIV in Malawi (PROSPECT Study)

Background: Adults seeking diagnosis and treatment for tuberculosis (TB) and HIV in low-resource settings face considerable barriers and have high pre-treatment mortality. Efforts to improve access to prompt TB treatment have been hampered by limitations in TB diagnostics, with considerable uncertainty about how available and new tests can best be implemented. Design and methods: The PROSPECT Study is an open, three-arm pragmatic randomised study that will investigate the effectiveness and cost-effectiveness of optimised HIV and TB diagnosis and linkage to care interventions in reducing time to TB diagnosis and prevalence of undiagnosed TB and HIV in primary care in Blantyre, Malawi. Participants (≥ 18 years) attending a primary care clinic with TB symptoms (cough of any duration) will be randomly allocated to one of three groups: (i) standard of care; (ii) optimised HIV diagnosis and linkage; or (iii) optimised HIV and TB diagnosis and linkage. We will test two hypotheses: firstly, whether prompt linkage to HIV care should be prioritised for adults with TB symptoms; and secondly, whether an optimised TB triage testing algorithm comprised of digital chest x-ray evaluated by computer-aided diagnosis software and sputum GeneXpert MTB/Rif can outperform clinician-directed TB screening. The primary trial outcome will be time to TB treatment initiation by day 56, and secondary outcomes will include prevalence of undiagnosed TB and HIV, mortality, quality of life, and cost-effectiveness. Conclusions: The PROSPECT Study will provide urgently-needed evidence under "real-life" conditions to inform clinicians and policy makers on how best to improve TB/HIV diagnosis and treatment in Africa. Clinical trial registration: NCT03519425 (08/05/2018).

Design and protocol for a pragmatic randomised study to optimise screening, prevention and care for tuberculosis and HIV in Malawi (PROSPECT Study)

Background: Adults seeking diagnosis and treatment for tuberculosis (TB) and HIV in low-resource settings face considerable barriers and have high pre-treatment mortality. Efforts to improve access to prompt TB treatment have been hampered by limitations in TB diagnostics, with considerable uncertainty about how available and new tests can best be implemented. Design and methods: The PROSPECT Study is an open, three-arm pragmatic randomised study that will investigate the effectiveness and cost-effectiveness of optimised HIV and TB diagnosis and linkage to care interventions in reducing time to TB diagnosis and prevalence of undiagnosed TB and HIV in primary care in Blantyre, Malawi. Participants (≥ 18 years) attending a primary care clinic with TB symptoms (cough of any duration) will be randomly allocated to one of three groups: (i) standard of care; (ii) optimised HIV diagnosis and linkage; or (iii) optimised HIV and TB diagnosis and linkage. We will test two hypotheses: firstly, whether prompt linkage to HIV care should be prioritised for adults with TB symptoms; and secondly, whether an optimised TB triage testing algorithm comprised of digital chest x-ray evaluated by computer-aided diagnosis software and sputum GeneXpert MTB/Rif can outperform clinician-directed TB screening. The primary trial outcome will be time to TB treatment initiation by day 56, and secondary outcomes will include prevalence of undiagnosed TB and HIV, mortality, quality of life, and cost-effectiveness. Conclusions: The PROSPECT Study will provide urgently-needed evidence under "real-life" conditions to inform clinicians and policy makers on how best to improve TB/HIV diagnosis and treatment in Africa. Clinical trial registration: NCT03519425 (08/05/2018).

Brief counselling after home-based HIV counselling and testing strongly increases linkage to care: a cluster-randomized trial in Uganda

Introduction

The aim of this study was to determine whether counselling provided subsequent to HIV testing and referral for care increases linkage to care among HIV‐positive persons identified through home‐based HIV counselling and testing (HBHCT) in Masaka, Uganda.

Methods

The study was an open‐label cluster‐randomized trial. 28 rural communities were randomly allocated (1:1) to intervention (HBHCT, referral and counselling at one and two months) or control (HBHCT and referral only). HIV‐positive care‐naïve adults (≥18 years) were enrolled. To conceal participants’ HIV status, one HIV‐negative person was recruited for every three HIV‐positive participants. Primary outcomes were linkage to care (clinic‐verified registration for care) status at six months, and time to linkage. Primary analyses were intention‐to‐treat using random effects logistic regression or Cox regression with shared frailty, as appropriate.

Results

Three hundred and two(intervention, n = 149; control, n = 153) HIV‐positive participants were enrolled. Except for travel time to the nearest HIV clinic, baseline participant characteristics were generally balanced between trial arms. Retention was similar across trial arms (92% overall). One hundred and twenty‐seven (42.1%) participants linked to care: 76 (51.0%) in the intervention arm versus 51 (33.3%) in the control arm [odds ratio = 2.18, 95% confidence interval (CI) = 1.26–3.78; p = 0.008)]. There was evidence of interaction between trial arm and follow‐up time (p = 0.009). The probability of linkage to care, did not differ between arms in the first two months of follow‐up, but was subsequently higher in the intervention arm versus the control arm [hazard ratio = 4.87, 95% CI = 1.79–13.27, p = 0.002].

Conclusions

Counselling substantially increases linkage to care among HIV‐positive adults identified through HBHCT and may enhance efforts to increase antiretroviral therapy coverage in sub‐Saharan Africa.

Predictors of timely linkage-to-ART within universal test and treat in the HPTN 071 (PopART) trial in Zambia and South Africa: findings from a nested case-control study

INTRODUCTION

HPTN 071 (PopART) is a three-arm community randomized trial in Zambia and South Africa evaluating the impact of a combination HIV prevention package, including universal test and treat (UTT), on HIV incidence. This nested study examined factors associated with timely linkage-to-care and ART initiation (TLA) (i.e. within six-months of referral) in the context of UTT within the intervention communities of the HPTN 071 (PopART) trial.

METHODS

Of the 7572 individuals identified as persons living with HIV (PLWH) (and not on antiretroviral treatment (ART)) during the first year of the PopART intervention provided by Community HIV-care Providers (CHiPs) through door-to-door household visits, individuals who achieved TLA (controls) and those who did not (cases), stratified by gender and community, were randomly selected to be re-contacted for interview. Standardized questionnaires were administered to explore factors potentially associated with TLA, including demographic and behavioural characteristics, and participants' opinions on HIV and related services. Odds ratios comparing cases and controls were estimated using a multi-variable logistic regression.

RESULTS

Data from 705 participants (333 cases/372 controls) were analysed. There were negligible differences between cases and controls by demographic characteristics including age, marital or socio-economic position. Prior familiarity with the CHiPs encouraged TLA (aOR of being a case: 0.58, 95% CI: 0.39 to 0.86, p = 0.006). Participants who found clinics overcrowded (aOR: 1.51, 95% CI: 1.08 to 2.12, p = 0.006) or opening hours inconvenient (aOR: 1.63, 95% CI: 1.06 to 2.51, p = 0.02) were less likely to achieve TLA, as were those expressing stronger feelings of shame about having HIV (ptrend  = 0.007). Expressing "not feeling ready" (aOR: 2.75, 95% CI: 1.89 to 4.01, p < 0.001) and preferring to wait until they felt sick (aOR: 2.00, 95% CI: 1.27 to 3.14, p = 0.02) were similarly indicative of being a case. Worrying about being seen in the clinic or about how staff treated patients was not associated with TLA. While the association was not strong, we found that the greater the number of self-reported lifetime sexual partners the more likely participants were to achieve TLA (ptrend  = 0.06). There was some evidence that participants with HIV-positive partners on ART were less likely to be cases (aOR: 0.75, 95% CI: 0.53 to 1.06, p = 0.07).

DISCUSSION

The lack of socio-demographic differences between cases and controls is encouraging for a "universal" intervention that seeks to ensure high coverage across whole communities. Making clinics more "patient-friendly" could enhance treatment uptake further. The finding that those with higher risk behaviour are more actively engaging with UTT holds promise for treatment-as-prevention.

Targeted Spontaneous Reporting: Assessing Opportunities to Conduct Routine Pharmacovigilance for Antiretroviral Treatment on an International Scale

Introduction

Targeted spontaneous reporting (TSR) is a pharmacovigilance method that can enhance reporting of adverse drug reactions related to antiretroviral therapy (ART). Minimal data exist on the needs or capacity of facilities to conduct TSR.

Objectives

Using data from the International epidemiologic Databases to Evaluate AIDS (IeDEA) Consortium, the present study had two objectives: (1) to develop a list of facility characteristics that could constitute key assets in the conduct of TSR; (2) to use this list as a starting point to describe the existing capacity of IeDEA-participating facilities to conduct pharmacovigilance through TSR.

Methods

We generated our facility characteristics list using an iterative approach, through a review of relevant World Health Organization (WHO) and Uppsala Monitoring Centre documents focused on pharmacovigilance activities related to HIV and ART and consultation with expert stakeholders. IeDEA facility data were drawn from a 2009/2010 IeDEA site assessment that included reported characteristics of adult and pediatric HIV care programs, including outreach, staffing, laboratory capacity, adverse event monitoring, and non-HIV care.

Results

A total of 137 facilities were included: East Africa (43); Asia–Pacific (28); West Africa (21); Southern Africa (19); Central Africa (12); Caribbean, Central, and South America (7); and North America (7). Key facility characteristics were grouped as follows: outcome ascertainment and follow-up; laboratory monitoring; documentation—sources and management of data; and human resources. Facility characteristics ranged by facility and region. The majority of facilities reported that patients were assigned a unique identification number (n = 114; 83.2 %) and most sites recorded adverse drug reactions (n = 101; 73.7 %), while 82 facilities (59.9 %) reported having an electronic database on site.

Conclusion

We found minimal information is available about facility characteristics that may contribute to pharmacovigilance activities. Our findings, therefore, are a first step that can potentially assist implementers and facility staff to identify opportunities and leverage their existing capacities to incorporate TSR into their routine clinical programs.

Retention Throughout the HIV Care and Treatment Cascade: From Diagnosis to Antiretroviral Treatment of Adults and Children Living with HIV-Haiti, 1985-2015

Monitoring retention of people living with HIV (PLHIV) in the HIV care and treatment cascade is essential to guide program strategy and evaluate progress toward globally-endorsed 90–90–90 targets (i.e., 90% of PLHIV diagnosed, 81% on sustained antiretroviral therapy (ART), and 73% virally suppressed). We describe national retention from diagnosis throughout the cascade for patients receiving HIV services in Haiti during 1985–2015, with a focus on those receiving HIV services during 2008–2015. Among the 266,256 newly diagnosed PLHIV during 1985–2015, 49% were linked-to-care, 30% started ART, and 18% were retained on ART by the time of database closure. Similarly, among the 192,187 newly diagnosed HIV-positive patients during 2008–2015, 50% were linked to care, 31% started ART, and 19% were retained on ART by the time of database closure. Most patients (90–92%) at all cascade steps were adults (≥ 15 years old), among whom the majority (60–61%) were female. During 2008–2015, outcomes varied significantly across 42 administrative districts (arrondissements) of residence; cumulative linkage-to-care ranged from 23% to 69%, cumulative ART initiation among care enrollees ranged from 2% to 80%, and cumulative ART retention among ART enrollees ranged from 30% to 88%. Compared with adults, children had lower cumulative incidence of ART initiation among care enrollees (64% versus 47%) and lower cumulative retention among ART enrollees (64% versus 50%). Cumulative linkage-to-care was low and should be prioritized for improvement. Variations in outcomes by arrondissement and between adults and children require further investigation and programmatic response.

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.

Factors associated with antiretroviral treatment initiation amongst HIV-positive individuals linked to care within a universal test and treat programme: early findings of the ANRS 12249 TasP trial in rural South Africa

Prompt uptake of antiretroviral treatment (ART) is essential to ensure the success of universal test and treat (UTT) strategies to prevent HIV transmission in high-prevalence settings. We describe ART initiation rates and associated factors within an ongoing UTT cluster-randomized trial in rural South Africa. HIV-positive individuals were offered immediate ART in the intervention arm vs. national guidelines recommended initiation (CD4≤350 cells/mm(3)) in the control arm. We used data collected up to July 2015 among the ART-eligible individuals linked to TasP clinics before January 2015. ART initiation rates at one (M1), three (M3) and six months (M6) from baseline visit were described by cluster and CD4 count strata (cells/mm(3)) and other eligibility criteria: ≤100; 100-200; 200-350; CD4>350 with WHO stage 3/4 or pregnancy; CD4>350 without WHO stage 3/4 or pregnancy. A Cox model accounting for covariate effect changes over time was used to assess factors associated with ART initiation. The 514 participants had a median [interquartile range] follow-up duration of 1.08 [0.69; 2.07] months until ART initiation or last visit. ART initiation rates at M1 varied substantially (36.9% in the group CD4>350 without WHO stage 3/4 or pregnancy, and 55.2-71.8% in the three groups with CD4≤350) but less at M6 (from 85.3% in the first group to 96.1-98.3% in the three other groups). Factors associated with lower ART initiation at M1 were a higher CD4 count and attending clinics with both high patient load and higher cluster HIV prevalence. After M1, having a regular partner was the only factor associated with higher likelihood of ART initiation. These findings suggest good ART uptake within a UTT setting, even among individuals with high CD4 count. However, inadequate staffing and healthcare professional practices could result in prioritizing ART initiation in patients with the lowest CD4 counts.

Overcoming Health System Challenges for Women and Children Living With HIV Through the Global Plan

To meet the ambitious targets set by the Global Plan Towards the Elimination of New HIV Infections Among Children by 2015 and Keeping Their Mothers Alive (Global Plan), the initial 22 priority countries quickly developed innovative approaches for overcoming long-standing health systems challenges and providing HIV testing and treatment to pregnant and breastfeeding women and their infants. The Global Plan spurred programs for prevention of mother-to-child HIV transmission to integrate HIV-related care and treatment into broader maternal, newborn, and child health services; expand the effectiveness of the health workforce through task sharing; extend health services into communities; strengthen supply chain and commodity management systems; reduce diagnostic and laboratory hurdles; and strengthen strategic supervision and mentorship. The article reviews the ongoing challenges for prevention of mother-to-child HIV transmission programs as they continue to strive for elimination of vertical transmission of HIV infection in the post-Global Plan era. Although progress has been rapid, health systems still face important challenges, particularly follow-up and diagnosis of HIV-exposed infants, continuity of care, and the promotion of services that are respectful and client centered.

Linkage into care among newly diagnosed HIV-positive individuals tested through outreach and facility-based HIV testing models in Mbeya, Tanzania: a prospective mixed-method cohort study

OBJECTIVE

Linkage to care is the bridge between HIV testing and HIV treatment, care and support. In Tanzania, mobile testing aims to address historically low testing rates. Linkage to care was reported at 14% in 2009 and 28% in 2014. The study compares linkage to care of HIV-positive individuals tested at mobile/outreach versus public health facility-based services within the first 6 months of HIV diagnosis.

SETTING

Rural communities in four districts of Mbeya Region, Tanzania.

PARTICIPANTS

A total of 1012 newly diagnosed HIV-positive adults from 16 testing facilities were enrolled into a two-armed cohort and followed for 6 months between August 2014 and July 2015. 840 (83%) participants completed the study.

MAIN OUTCOME MEASURES

We compared the ratios and time variance in linkage to care using the Kaplan-Meier estimator and Log rank tests. Cox proportional hazards regression models to evaluate factors associated with time variance in linkage.

RESULTS

At the end of 6 months, 78% of all respondents had linked into care, with differences across testing models. 84% (CI 81% to 87%, n=512) of individuals tested at facility-based site were linked to care compared to 69% (CI 65% to 74%, n=281) of individuals tested at mobile/outreach. The median time to linkage was 1 day (IQR: 1-7.5) for facility-based site and 6 days (IQR: 3-11) for mobile/outreach sites. Participants tested at facility-based site were 78% more likely to link than those tested at mobile/outreach when other variables were controlled (AHR=1.78; 95% CI 1.52 to 2.07). HIV status disclosure to family/relatives was significantly associated with linkage to care (AHR=2.64; 95% CI 2.05 to 3.39).

CONCLUSIONS

Linkage to care after testing HIV positive in rural Tanzania has increased markedly since 2014, across testing models. Individuals tested at facility-based sites linked in significantly higher proportion and modestly sooner than mobile/outreach tested individuals. Mobile/outreach testing models bring HIV testing services closer to people. Strategies to improve linkage from mobile/outreach models are needed.

An open-label cluster randomised trial to evaluate the effectiveness of a counselling intervention on linkage to care among HIV-infected patients in Uganda: Study design

Introduction

Home-based HIV counselling & testing (HBHCT) is highly acceptable and has the potential to increase HIV testing uptake in sub-Saharan Africa. However, data are lacking on strategies that can effectively link HIV-positive individuals identified through HBHCT to care. This trial was designed to assess the effectiveness of two brief home-based counselling sessions on linkage to care, provided subsequent to referral for care among HIV-positive patients identified through HBHCT in a rural community in Masaka district, Uganda.

Methods

28 communities (clusters) were randomly allocated to control (referral only) and intervention (referral and follow-up counselling) arms (n = 14 clusters/arm). Randomisation was stratified on distance from the district capital (≤10 km vs > 10 km) and cluster size (larger single village vs combined small villages), and restricted to ensure balance on selected cluster characteristics. A list of possible allocations was generated and one randomly selected at a public ceremony. HBHCT is being offered to all adults (≥18 years), and HIV-positive individuals not yet in care are eligible for enrolment. The intervention is provided at one and two months post-enrolment. Primary outcomes, assessed 6 months after enrolment, are: the proportion of individuals linking to HIV care within 6 months of HIV diagnosis and time to linkage. The primary analysis will be based on individual-level data.

Discussion

This study will provide evidence on the impact of a counselling intervention on linkage to care among adults identified with HIV infection through HBHCT. Interpretation of the trial outcomes will be aided by results from an on-going qualitative sub-study.

Uptake contexts and perceived impacts of HIV testing and counselling among adults in East and Southern Africa: A meta-ethnographic review

INTRODUCTION

HIV testing and counselling (HTC) interventions are key to controlling the HIV epidemic in East and Southern Africa where HTC is primarily delivered through voluntary counselling and testing (VCT), provider initiated testing and counselling (PITC), and home-based counselling and testing (HBVCT). Decision making processes around uptake of HTC models must be taken into account when designing new interventions. Counselling in HTC aims to reduce post-test risk taking behaviour and to link individuals to care but its efficacy is unclear. This meta-ethnography aims to understand the contexts of HTC uptake in East and Southern Africa and to analyse the perceived impacts of counselling-based interventions in relation to sexual behaviour and linkage to care.

METHODS

We conducted a systematic literature review of studies investigating HTC in East and Southern Africa from 2003 -April 2014. The search and additional snowballing identified 20 studies that fit our selection criteria. These studies were synthesised through a thematic framework analysis.

RESULTS

Twenty qualitative and mixed-methods studies examining impacts of HTC models in East and Southern Africa were meta-synthesised. VCT decisions were made individually while HBVCT decisions were located in family and community units. PITC was associated with coercion from healthcare providers. Low quality counselling components and multiple-intersecting barriers faced by individuals mean that counselling in HTC was not perceived to be effective in reducing post-test risk behaviour and had limited perceived effect in facilitating linkage to care.

CONCLUSION

HBVCT is associated with minimal stigma and should be considered as an area of priority. Counselling components in HTC interventions were effective in transmitting information about HIV and sexual risk, but were perceived as ineffective in addressing the broader personal circumstances preventing sexual behaviour change and modulating access to care.

Identifying common barriers and facilitators to linkage and retention in chronic disease care in western Kenya

Background

Sub-Saharan Africa is increasingly being challenged in providing care and treatment for chronic diseases, both communicable and non-communicable. In order to address the challenges of linkage to and retention in chronic disease management, there is the need to understand the factors that can influence engagement in care. We conducted a qualitative study to identify barriers and facilitators to linkage and retention in chronic care for HIV, tuberculosis (TB) and Hypertension (HTN) as part of the Academic Model Providing Access to Healthcare (AMPATH) program in western Kenya.

Methods

In-depth interviews and focus group discussions were conducted July 2012-August 2013. Study participants were purposively sampled from three AMPATH clinics and included patients within the AMPATH program receiving HIV, TB, and HTN care, as well as caregivers of children with HIV, community leaders, and healthcare providers. A set of interview guides were developed to explore perceived barriers and facilitators to chronic disease management, particularly related to linkage to and retention in HIV, TB and HTN care. Data were coded and various themes were identified. We organized the concepts and themes generated using the Andersen-Newman Framework of Health Services Utilization.

Results

A total of 235 participants including 110 individuals living with HIV (n = 50), TB (n = 39), or HTN (n = 21); 24 caregivers; 10 community leaders; and 62 healthcare providers participated. Barriers and facilitators were categorized as predisposing characteristics, enabling resources and need factors. Many of the facilitators and barriers reported in this study were consistently reported across disease categories including personal drive, patient-provider relationships and the need for social and peer support.

Conclusions

Our findings provide insight into the individual as well as broader structural factors that can deter or encourage linkage and retention that are relevant across communicable and non-communicable chronic diseases. The findings of the present study suggest that interventions should consider the logistical aspects of accessing care in addition to predisposing and need factors that may affect an individuals’ decision to seek out and remain in appropriate care.

The Sensitivity and Specificity of Loop-Mediated Isothermal Amplification (LAMP) Assay for Tuberculosis Diagnosis in Adults with Chronic Cough in Malawi

BACKGROUND

Current tuberculosis diagnostics lack sensitivity, and are expensive. Highly accurate, rapid and cheaper diagnostic tests are required for point of care use in low resource settings with high HIV prevalence.

OBJECTIVE

To investigate the sensitivity and specificity, and cost of loop-mediated isothermal amplification (LAMP) assay for tuberculosis diagnosis in adults with chronic cough compared to Xpert® MTB/RIF, fluorescence smear microscopy.

METHODS

Between October 2013 and March 2014, consecutive adults at a primary care clinic were screened for cough, offered HIV testing and assessed for tuberculosis using LAMP, Xpert® MTB/RIF and fluorescence smear microscopy. Sensitivity and specificity (with culture as reference standard), and costs were estimated.

RESULTS

Of 273 adults recruited, 44.3% (121/273) were HIV-positive and 19.4% (53/273) had bacteriogically confirmed tuberculosis. The sensitivity of LAMP compared to culture was 65.0% (95% CI: 48.3% to 79.4%) with 100% (95% CI: 98.0% to 100%) specificity. The sensitivity of Xpert® MTB/RIF (77.5%, 95% CI: 61.5% to 89.2%) was similar to that of LAMP, p = 0.132. The sensitivity of concentrated fluorescence smear microscopy with routine double reading (87.5%, 95% CI: 73.2% to 95.8%) was higher than that of LAMP, p = 0.020. All three tests had high specificity. The lowest cost per test of LAMP was at batch size of 14 samples (US$ 9.98); this was lower than Xpert® MTB/RIF (US$ 13.38) but higher than fluorescence smear microscopy (US$ 0.65).

CONCLUSION

The sensitivity of LAMP was similar to Xpert® MTB/RIF but lower than fluorescence smear microscopy; all three tests had high specificity. These findings support the Malawi policy that recommends a combination of fluorescence smear microscopy and Xpert® MTB/RIF prioritised for people living with HIV, already found to be smear-negative, or being considered for retreatment of tuberculosis.

Evaluating facility-based antiretroviral therapy programme effectiveness: a pilot study comparing viral load suppression and retention rates

OBJECTIVES

Increased demand for antiretroviral therapy (ART) services combined with plateaued levels of development assistance for HIV/AIDS requires that national ART programmes monitor programme effectiveness. In this pilot study, we compared commonly utilised performance metrics of 12- and 24-month retention with rates of viral load (VL) suppression at 15 health facilities in Uganda.

METHODS

Retrospective chart review from which 12- and 24-month retention rates were estimated, and parallel HIV RNA VL testing on consecutive adult patients who presented to clinics and had been on ART for a minimum of six months. Rates of VL suppression were then calculated at each facility and compared to retention rates to assess the correlation between performance metrics. Multilevel logistic regression models predicting VL suppression and 12- and 24-month retention were constructed to estimate facility effects.

RESULTS

We collected VL samples from 2961 patients and found that 88% had a VL ≤1000 copies/ml. Facility rates of VL suppression varied between 77% and 96%. When controlling for patient mix, a significant variation in facility performance persisted. Retention rates at 12 and 24 months were 91% and 79%, respectively, with a comparable facility-level variation. However, neither 12-month (ρ = 0.16) nor 24-month (ρ = -0.19) retention rates were correlated with facility rates of VL suppression.

CONCLUSIONS

Retaining patients in care and suppressing VL are both critical outcomes. Given the lack of correlation noted in this study, the utilisation of VL monitoring may be necessary to truly assess the effectiveness of health facilities delivering ART services.

Why Did I Stop? Barriers and Facilitators to Uptake and Adherence to ART in Option B+ HIV Care in Lilongwe, Malawi

Causes for loss-to-follow-up, including early refusals of and stopping antiretroviral therapy (ART), in Malawi's Option B+ program are poorly understood. This study examines the main barriers and facilitators to uptake and adherence to ART under Option B+. In depth interviews were conducted with HIV-infected women who were pregnant or postpartum in Lilongwe, Malawi (N = 65). Study participants included women who refused ART initiation (N = 10), initiated ART and then stopped (N = 26), and those who initiated ART and remained on treatment (N = 29). The barriers to ART initiation were varied and included concerns about partner support, feeling healthy, and needing time to think. The main reasons for stopping ART included side effects and lack of partner support. A substantial number of women started ART after initially refusing or stopping ART. There were several facilitators for re-starting ART, including encouragement from community health workers, side effects subsiding, decline in health, change in partner, and fear of future sickness. Amongst those who remained on ART, desire to prevent transmission and improve health were the most influential facilitators. Reasons for refusing and stopping ART were varied. ART-related side effects and feeling healthy were common barriers to ART initiation and adherence. Providing consistent pre-ART counseling, early support for patients experiencing side effects, and targeted efforts to bring women who stop treatment back into care may improve long term health outcomes.

Simplified HIV Testing and Treatment in China: Analysis of Mortality Rates Before and After a Structural Intervention

BACKGROUND

Multistage stepwise HIV testing and treatment initiation procedures can result in lost opportunities to provide timely antiretroviral therapy (ART). Incomplete patient engagement along the continuum of HIV care translates into high levels of preventable mortality. We aimed to evaluate the ability of a simplified test and treat structural intervention to reduce mortality.

METHODS AND FINDINGS

In the "pre-intervention 2010" (from January 2010 to December 2010) and "pre-intervention 2011" (from January 2011 to December 2011) phases, patients who screened HIV-positive at health care facilities in Zhongshan and Pubei counties in Guangxi, China, followed the standard-of-care process. In the "post-intervention 2012" (from July 2012 to June 2013) and "post-intervention 2013" (from July 2013 to June 2014) phases, patients who screened HIV-positive at the same facilities were offered a simplified test and treat intervention, i.e., concurrent HIV confirmatory and CD4 testing and immediate initiation of ART, irrespective of CD4 count. Participants were followed for 6-18 mo until the end of their study phase period. Mortality rates in the pre-intervention and post-intervention phases were compared for all HIV cases and for treatment-eligible HIV cases. A total of 1,034 HIV-positive participants (281 and 339 in the two pre-intervention phases respectively, and 215 and 199 in the two post-intervention phases respectively) were enrolled. Following the structural intervention, receipt of baseline CD4 testing within 30 d of HIV confirmation increased from 67%/61% (pre-intervention 2010/pre-intervention 2011) to 98%/97% (post-intervention 2012/post-intervention 2013) (all p < 0.001 [i.e., for all comparisons between a pre- and post-intervention phase]), and the time from HIV confirmation to ART initiation decreased from 53 d (interquartile range [IQR] 27-141)/43 d (IQR 15-113) to 5 d (IQR 2-12)/5 d (IQR 2-13) (all p < 0.001). Initiation of ART increased from 27%/49% to 91%/89% among all cases (all p < 0.001) and from 39%/62% to 94%/90% among individuals with CD4 count ≤ 350 cells/mm3 or AIDS (all p < 0.001). Mortality decreased from 27%/27% to 10%/10% for all cases (all p < 0.001) and from 40%/35% to 13%/13% for cases with CD4 count ≤ 350 cells/mm3 or AIDS (all p < 0.001). The simplified test and treat intervention was significantly associated with decreased mortality rates compared to pre-intervention 2011 (adjusted hazard ratio [aHR] 0.385 [95% CI 0.239-0.620] and 0.380 [95% CI 0.233-0.618] for the two post-intervention phases, respectively, for all newly diagnosed HIV cases [both p < 0.001], and aHR 0.369 [95% CI 0.226-0.603] and 0.361 [95% CI 0.221-0.590] for newly diagnosed treatment-eligible HIV cases [both p < 0.001]). The unit cost of an additional patient receiving ART attributable to the intervention was US$83.80. The unit cost of a death prevented because of the intervention was US$234.52.

CONCLUSIONS

Our results demonstrate that the simplified HIV test and treat intervention promoted successful engagement in care and was associated with a 62% reduction in mortality. Our findings support the implementation of integrated HIV testing and immediate access to ART irrespective of CD4 count, in order to optimize the impact of ART.

Barriers to antiretroviral treatment initiation in rural KwaZulu-Natal, South Africa

OBJECTIVES

Although antiretroviral therapy (ART) has been freely available since 2004 in South Africa, not all those who are eligible initiate ART. We aimed to investigate individual and household characteristics as barriers to ART initiation in men and women in rural KwaZulu-Natal.

METHODS

Adults ≥ 16 years old living within a sociodemographic surveillance area (DSA) who accessed the local HIV programme between 2007 and 2011 were included in the study. Individual and household factors associated with ART initiation within 3 months of becoming eligible for ART were investigated using multivariable logistic regression stratified by sex and after exclusion of individuals who died before initiating ART.

RESULTS

Of the 797 men and 1598 women initially included, 8% and 5.5%, respectively, died before ART initiation and were excluded from further analysis. Of the remaining 733 men and 1510 women, 68.2% and 60.2%, respectively, initiated ART ≤ 3 months after becoming eligible (P = 0.34 after adjustment for CD4 cell count). In men, factors associated with a higher ART initiation rate were being a member of a household located < 2 km from the nearest HIV clinic and being resident in the DSA at the time of ART eligibility. In women, ART initiation was more likely in those who were not pregnant, in members of a household where at least one person was on ART and in those with a high wealth index.

CONCLUSIONS

In this rural South African setting, barriers to ART initiation differed for men and women. Supportive individual- and household-level interventions should be developed to guarantee rapid ART initiation taking account gender specificities.

Understanding treatment refusal among adults presenting for HIV-testing in Soweto, South Africa: a qualitative study

HIV treatment initiatives have focused on increasing access to antiretroviral therapy (ART). There is growing evidence, however, that treatment availability alone is insufficient to stop the epidemic. In South Africa, only one third of individuals living with HIV are actually on treatment. Treatment refusal has been identified as a phenomenon among people who are asymptomatic, however, factors driving refusal remain poorly understood. We interviewed 50 purposively sampled participants who presented for voluntary counseling and testing in Soweto to elicit a broad range of detailed perspectives on ART refusal. We then integrated our core findings into an explanatory framework. Participants described feeling "too healthy" to start treatment, despite often having a diagnosis of AIDS. This subjective view of wellness was framed within the context of treatment being reserved for the sick. Taking ART could also lead to unintended disclosure and social isolation. These data provide a novel explanatory model of treatment refusal, recognizing perceived risks and social costs incurred when disclosing one's status through treatment initiation. Our findings suggest that improving engagement in care for people living with HIV in South Africa will require optimizing social integration and connectivity for those who test positive.

Health facility barriers to HIV linkage and retention in Western Kenya

Background

HIV linkage and retention rates in sub-Saharan Africa remain low. The objective of this study was to explore perceived health facility barriers to linkage and retention in an HIV care program in western Kenya.

Methods

This qualitative study was conducted July 2012-August 2013. A total of 150 participants including; 59 patients diagnosed with HIV, TB, or hypertension; 16 caregivers; 10 community leaders; and 65 healthcare workers, were purposively sampled from three Academic Model Providing Access to Healthcare (AMPATH) sites. We conducted 16 in-depth interviews and 17 focus group discussions (FGDs) in either, English, Swahili, Kalenjin, Teso, or Luo. All data were audio recorded, transcribed, translated to English, and a content analysis performed. Demographic data was only available for those who participated in the FGDs.

Results

The mean age of participants in the FGDs was 36 years (SD = 9.24). The majority (87%) were married, (62.7%) had secondary education level and above, and (77.6%) had a source of income. Salient barriers identified reflected on patients’ satisfaction with HIV care. Barriers unique to linkage were reported as quality of post-test counseling and coordination between HIV testing and care. Those unique to retention were frequency of clinic appointments, different appointments for mother and child, lack of HIV care for institutionalized populations including students and prisoners, lack of food support, and inconsistent linkage data. Barriers common to both linkage and retention included access to health facilities, stigma associated with health facilities, service efficiency, poor provider-patient interactions, and lack of patient incentives.

Conclusion

Our findings revealed that there were similarities and differences between perceived barriers to linkage and retention. The cited barriers reflected on the need for a more patient-centered approach to HIV care. Addressing health facility barriers may ultimately be more efficient and effective than addressing patient related barriers.

Characteristics and outcomes of HIV-infected youth and young adolescents enrolled in HIV care in Kenya

BACKGROUND

The number of youth and adolescents (10-24 years) with HIV infection has increased substantially presenting unique challenges to effective health service delivery.

METHODS

We examined routinely collected patient-level data for antiretroviral treatment (ART)-naive HIV-infected patients, aged 10-24 years, enrolled in care during 2006-2011 at 109 ICAP-supported health facilities in three provinces in Kenya. Loss to follow-up (LTF) was defined as having no clinic visit for 12 months prior to ART initiation (pre-ART) and 6 months for ART patients. Competing risk and Kaplan-Meier estimators were used to calculate LTF and death rates. Sub-distributional and Cox proportional-hazards models were used to identify potential predictors of death and LTF.

RESULTS

Overall 22 832 patients were enrolled in care at 10-24 years of age, 69.5% were aged 20-24 years, and 82% were female. Median CD4(+) cell count was 332 cells/μl (interquartile range 153-561); 70.8% were WHO stage I/II. Young adolescents (10-14 years) had more advanced WHO stage and lower median CD4(+) cell count compared to youth (15-24 years) at enrollment (284 vs. 340 cells/μl; P < 0.0001). Cumulative incidence of LTF and death at 24 months for pre-ART patients was 46.1% [95% confidence interval (CI) 45.4-46.8%) and 2.1% (95% CI 1.9-2.3%), respectively. For those on ART, 32.2% (95% CI 31.1-33.3%) were LTF and 3.9% (95% CI 1.7-2.3%) died within 24 months. LTF among pre-ART and ART patients was twice as high among youth compared to young adolescents.

CONCLUSION

LTF of young people with HIV in this Kenyan cohort was high and notably greater among youth compared to young adolescents. Novel strategies targeting these populations are urgently needed to improve retention.