Interventions to improve or facilitate linkage to or retention in pre-ART (HIV) care and initiation of ART in low- and middle-income settings--a systematic review

Enhancing Antiretroviral Therapy Initiation for Hospitalized and Recently Discharged People Living With HIV in Johannesburg, South Africa

BACKGROUND

Despite increased antiretroviral therapy (ART) access in South Africa, HIV testing and ART initiation are suboptimal in hospital settings. Key gaps include in-hospital case finding, ART initiation support, and primary health care (PHC) facility linkage after discharge.

INTERVENTION DEVELOPMENT AND DESCRIPTION

We identified weaknesses in hospital processes by comparing them with PHC HIV services and developed a quality improvement model for implementation in 5 Johannesburg hospitals. We introduced dedicated teams of HIV testing counselors for structured case finding and ART-trained nurses and linkage officers to provide in-hospital or post-discharge ART initiation and support to strengthen PHC facility linkage. Monitoring data (May 2020-March 2021) was used to measure initiation rates.

LESSONS LEARNED

Over 11 months, despite COVID-19 pandemic-related disruptions, our model achieved 74% (5,201/7,025) ART linkage within 28 days post-discharge and 87% (6,087/7,025) overall, including all initiations (i.e., all newly diagnosed, known not on ART and reinitiating individuals). The 2 highest-performing hospitals achieved 97% (2,096/2,170) linkage overall, demonstrating the potential of implementing this quality improvement model with fidelity. Over half (58%, 4,092/7,025) of patients initiated ART within 7 days, with 39% (2,748) initiating on the same day. Women and men achieved similar initiation rates (3,010/4,015, 75%; 2,186/3,003, 73%, respectively). Combining rapid (<7 days) in-hospital ART initiation with 28-day post-discharge follow-up supported high ART initiation rates. Using the model mitigated initiation gaps for men and older people, engaging stakeholders supported implementation, and using a team-based approach founded on clear roles and responsibilities improved service delivery.

CONCLUSION

This model achieved above-average ART linkage rates in a large hospitalized population. We recommend considering introducing this model or adaptations of it to hospitals across South Africa and similar settings where hospital-to-PHC ART service gaps are identified to optimize case finding, ART initiation, and post-discharge linkage support.

Tushirikiane-4-Uthabiti (Supporting Each Other For Resilience): study protocol of a mental health, HIV self-testing and livelihoods randomised controlled trial for advancing HIV prevention outcomes among urban refugee youth in Kampala, Uganda

INTRODUCTION

Research with urban refugee youth in Uganda has documented co-occurring social (e.g., poverty) and health (e.g., depression) disparities associated with HIV vulnerabilities. Benefits of HIV self-testing (HIVST) in increasing HIV testing uptake among youth are well established, yet limited interventions have examined if combining HIVST with mental health promotion, or with mental health promotion alongside poverty reduction, is associated with greater improvements in HIV prevention and testing outcomes.

METHODS AND ANALYSIS

The aim is to evaluate the effectiveness of: (1) HIVST alone (standard of care); (2) mobile health (mHealth) and graphic medicine (comic) programme for mental health alongside HIVST; and (3) the combination of HIVST, a livelihoods programme, and mHealth mental health programme, in advancing the primary outcome of HIV testing uptake and secondary outcomes (HIV status knowledge, linkage to confirmatory testing and HIV care, HIV knowledge, consistent condom use, condom use self-efficacy, sexual risk) with urban refugee youth in Kampala, Uganda. A three-arm randomised controlled trial will be implemented from 8 April 2024 to 31 October 2024 with youth across five informal settlements in Kampala, grouped into three sites based on proximity, and randomised in a 1:1:1 design. Approximately 330 participants (110 per arm) are enrolled and data collection will occur at three time points (baseline enrolment, 3-month follow-up and 6-month follow-up).

ETHICS AND DISSEMINATION

The study received ethical approval from the University of Toronto (#37496), Mildmay Uganda Research Ethics Committee (#MUREC-2021-41) and Uganda National Council for Science & Technology (#SS1021ES). The trial is registered at ClinicalTrials.gov (NCT06270160). Study findings will produce new knowledge of the impacts of a mental health programme, and a combined mental health and livelihoods programme, on improving HIV prevention outcomes among urban refugee youth in Kampala. Findings will be shared in peer-reviewed publications, conference presentations and in community dissemination.

TRIAL REGISTRATION NUMBER

NCT06270160 (date of registration: 13 February 2024).

TRIAL SPONSOR

Dr. Carmen Logie, carmen.logie@utoronto.ca.

Including the Household: Individual, Community and Household Factors Affecting Antiretroviral Therapy Adherence After ART Initiation in Cape Town, South Africa

Antiretroviral therapy (ART) adherence is crucial for health outcomes of people living with HIV (PLHIV), influenced by a complex interplay of individual, community, and household factors. This article focuses on the influence of household factors, as well as individual and community factors, on ART adherence among PLHIV in Cape Town who have recently initiated ART. Baseline data for a cluster-randomized controlled trial were collected from 316 PLHIV in 12 districts in Cape Town between 6th May 2021 and 22nd May 2022. Zero-inflated Poisson models, with cluster-adjusted standard errors, were used to analyse the association between individual, household, and community factors and ART adherence measures. At the household-level, household support was associated with both better self-rated adherence (exp(β) = 0.81, z =  - 4.68, p < 0.001) and fewer days when pills were missed (exp(β) = 0.65, z =  - 2.92, p = 0.003). Psychological violence (exp(β) = 1.37, z = 1.97, p = 0.05) and higher household asset scores (exp(β) = 1.29, z =  - 2.83, p = 0.05) were weakly associated with poorer ART adherence. At the individual-level, male gender (exp(β) = 1.37, z = 3.95, p < 0.001) and reinitiating ART (exp(β) = 1.35, z = 3.64, p < 0.001) were associated with worse self-rated ART adherence; higher education levels (exp(β) = 0.30 times, z =  - 3.75, p < 0.001) and better HIV knowledge (exp(β) = 0.28, z =  - 2.83, p = 0.005) were associated with fewer days where pills were missed. At the community-level, community stigma was associated with worse self-rated ART adherence (exp(β) = 1.24, z = 3.01, p = 0.003). When designing interventions to improve ART adherence, household, individual and community factors should all be considered, particularly in addressing gender-based disparities, reducing stigma, tackling violence, and enhancing household support.Clinical Trial Number: Pan African Clinical Trial Registry, PACTR201906476052236. Registered on 24 June 2019.

Health System Responses to Address Treatment Gaps of Unsuppressed Adolescents on HIV Treatment in Public Primary Health Care Facilities in Windhoek, Namibia

Background

Adolescents living with HIV (ALHIV) face unique challenges that result in persistent gaps in achieving and maintaining suppressed viral load. Although effective evidence-based interventions to address treatment gaps in adolescents are readily available, health systems in resource-constrained, high HIV prevalence settings are challenged to implement them to achieve epidemic control. Here, we describe the health system responses to address the treatment gap of unsuppressed ALHIV on antiretroviral therapy in Windhoek, Namibia.

Methods

We conducted a qualitative descriptive and exploratory study in Windhoek between June and October 2023. Nineteen purposively selected key informants, ranging from pediatric HIV program managers to healthcare providers, were interviewed. In-depth interviews were audio-recorded and transcribed verbatim. The transcripts were uploaded to ATLAS.ti and subjected to thematic analysis.

Results

The four main themes elucidated challenges related to adherence and retention as well as health system responses in the form of interventions and support programs. The predominant adherence and retention challenges faced by ALHIV were mental health issues, behavioral and medication-related challenges, and inadequate care and social support. The health system responses to the identified challenges included providing psychosocial support, peer support, optimization of treatment and care, and the utilization of effective service delivery models. Key health system support elements identified included adequately capacitated human resources, efficient medication supply chain systems, creating and maintaining an enabling environment for optimum care, and robust monitoring systems as essential to program success.

Conclusion

The health system responses to address the remaining treatment gaps of unsuppressed ALHIV in Windhoek are quite varied and, although evidence-based, appear to be siloed. We recommend harmonized, multifaceted guidance, integrating psychosocial, treatment, care, and peer-led support, and strengthening client-centred differentiated service delivery models for unsuppressed adolescents.

Implementation strategies to improve HIV care cascade outcomes in low- and middle-income countries: a systematic review from 2014 to 2021

INTRODUCTION

In low- and middle-income countries (LMICs), which are disproportionately affected by the HIV epidemic and manage limited resources, optimized implementation strategies are needed to enhance the efficiency of the HIV response. Assessing strategy usage to date could identify research gaps and inform future implementation efforts. We conducted a systematic review to describe the features and distributions of published implementation strategies attempting to improve HIV treatment service delivery and outcomes.

METHODS

We searched PubMed, Embase, and CINAHL and screened abstracts and full texts published between 1 January 2014 and 27 August 2021, for English-language studies conducted in LMICs that described the implementation of HIV intervention and reported at least one HIV care cascade outcome, ranging from HIV testing to viral suppression. Implementation strategies were inductively specified, characterized by unique combinations of actor, action and action target, and summarized based on existing implementation strategy taxonomies. All strategies included in this study were independently reviewed to ensure accuracy and consistency.

RESULTS

We identified 44,126 abstracts and reviewed 1504 full-text manuscripts. Among 485 included studies, 83% were conducted in sub-Saharan Africa; the rest were conducted in South-East Asia and Western Pacific (12%), and the Americas (8%). A total of 7253 unique implementation strategies were identified, including changing health service delivery (48%) and providing capacity building and support strategies (34%). Healthcare providers and researchers led 59% and 28% of the strategies, respectively. People living with HIV and their communities (62%) and healthcare providers (38%) were common strategy targets. Strategies attempting to change governance, financial arrangements and implementation processes were rarely reported.

DISCUSSION

We identified a range of published implementation strategies that addressed HIV cascade outcomes, though some key gaps exist. We may need to expand the application of implementation strategies to ensure that all stakeholders are meaningfully involved to support equitable implementation efforts across the geographic regions and target populations, and to optimize implementation outcomes.

CONCLUSIONS

Some health service delivery and capacity building and support strategies have been most commonly used to date. Future research and implementation may incorporate a more diverse range of strategies and detailed reporting on their usage to inform improved HIV responses globally.

"If It Weren't for This, We'd Be Sick"-Perspectives From Participants of a Couple-Based HIV Treatment and Support Program During Prenatal and Postpartum Periods in Zambézia Province, Mozambique

BACKGROUND

Engagement in HIV care and treatment services during pregnancy is key to eliminating vertical transmission. One barrier to retention of pregnant and lactating women is insufficient support from male partners. Reframing HIV services as couple-based may increase adherence among men and women. As part of a cluster randomized trial evaluating an intervention offering seroconcordant couples living with HIV joint follow-up in HIV services and sessions with a health counselor and couple peer educators, we assessed participants' perspectives and experiences regarding the intervention.

SETTING

Zambézia Province is a rural, low-income, and medically underserved region of central Mozambique.

METHODS

We conducted semistructured interviews with a subset of participants enrolled in the intervention arm. The objectives were to explore participants' (1) experiences with couples-based HIV care and the educational/support sessions; (2) perceived impacts of the intervention; and (3) suggestions for intervention improvement. Interviews conducted by experienced interviewers were audio-recorded, transcribed, and deductively coded.

RESULTS

Sixty-four participants were interviewed. Participants described the counselor and the peer educators as trustworthy and the sessions as improving their HIV-related knowledge. Receiving joint HIV services was convenient and motivated some participants to remain adherent to care. Participants provided few suggestions to improve the intervention, although a few female participants did state that they wished their male partners had participated more readily in the joint sessions and medication pick-ups at the health facilities.

CONCLUSIONS

Participants described positive experiences with and perceived benefits from the intervention, making this intervention acceptable within the local context.

Patient navigation for perinatal substance use disorder treatment: A systematic review

BACKGROUND

Substance use during the perinatal period (i.e., pregnancy through the first year postpartum) can pose significant maternal and infant health risks. However, access to lifesaving medications and standard care remains low for perinatal persons who use substances. This lack of substance use disorder treatment access stems from fragmented services, stigma, and social determinants of health-related barriers that could be addressed using patient navigators. This systematic review describes patient navigation models of care for perinatal people who use substances and associated outcomes.

METHODS

We conducted a structured search of peer-reviewed, US-focused, English- or Spanish-language articles from 2000 to 2023 focused on 1) patient navigation, 2) prenatal and postpartum care, and 3) substance use treatment programs using PubMed, Scopus, PsycINFO, and CINAHL databases.

RESULTS

After meeting eligibility criteria, 17 studies were included in this review. The majority (n=8) described outpatient patient navigation programs, with notable hospital (n=4) and residential (n=3) programs. Patient navigation was associated with reduced maternal substance use, increased receipt of services, and improved maternal and neonatal health. Findings were mixed for engagement in substance use disorder treatment and child custody outcomes. Programs that co-located care, engaged patients across the perinatal period, and worked to build trust and communication with family members and service providers were particularly successful.

CONCLUSION

Patient navigation may be a promising strategy for improving maternal and infant health outcomes among perinatal persons who use substances. More experimental research is needed to test the effect of patient navigation programs for perinatal persons who use substances compared to other models of care.

INcentives and ReMINDers to Improve Long-Term Medication Adherence (INMIND): impact of a pilot randomized controlled trial in a large HIV clinic in Uganda

INTRODUCTION

Habits are a common strategy for successfully countering medication non-adherence, yet existing interventions do not support participants during the long habit formation period, resulting in high attrition. We test a novel intervention combining text messages and incentives with anchoring to support antiretroviral therapy (ART) pill-taking habits.

METHODS

In a randomized, parallel controlled trial, a sample of 155 participants 18 years and older who initiated ART within 3 months were recruited at Mildmay Uganda between October 2021 and April 2022. All participants were educated on the anchoring strategy and chose an anchor, that is existing routines, to pair with pill-taking. Participants were randomized to either usual care (C = 49), daily text message reminders to follow their anchoring plan (Messages group; T1 = 49) or messages and incentives conditional on pill-taking in line with their anchor (Incentives group; T2 = 57). Assessments occurred at baseline, month 3 (end of intervention) and month 9 (end of observation period). The primary outcomes are electronically measured mean adherence and pill-taking consistent with participants' anchor time.

RESULTS

The primary outcome of pill-taking in line with the anchoring plan was higher in the Incentives group during the 3-month intervention (12.2 p.p. [95% CI: 2.2 22.2; p = .02]), and remained significantly higher after the incentives were withdrawn (months 4-6 (14.2 p.p. [95% CI 1.1 27.2; p = .03]); months 7-9 (14.1 p.p. [95% CI -0.2 28.5; p = .05])). Mean adherence was higher in both treatment groups relative to the control group during the intervention (T1 vs. C, p = .06; T2 vs. C, p = .06) but not post-intervention.

CONCLUSIONS

The promising approach of using incentives to support habit formation among ART treatment initiators needs to be evaluated in a fully powered study to further our understanding of the habit formation process and to evaluate its cost-effectiveness.

Digital Intervention Services to Promote HIV Self-Testing and Linkage to Care Services: A Bibliometric and Content Analysis-Global Trends and Future Directions

Objective: The global burden of HIV remains a critical public health challenge, particularly in sub-Saharan Africa, home to over two-thirds of individuals living with HIV. HIV self-testing (HIVST) has emerged as a promising strategy endorsed by the World Health Organization to achieve UNAIDS targets. Despite its potential, challenges persist in linking self-testers to care post a positive result. Digital health interventions, including chatbots and mobile applications, offer innovative solutions to address this gap. However, a comprehensive bibliometric analysis of the collaboration and growth in the literature at the intersection of HIVST and digital interventions is lacking. Methods: The study employs a bibliometric approach, leveraging data from the Web of Science, to analyze the characteristics, citation pattern and content of 289 articles spanning 1992-2023. The analysis involves performance assessment, scientific collaboration analysis, science mapping, and content analysis. Key bibliometric indicators, such as annual growth rate, citation impact, and authorship patterns, are explored. Collaboration patterns among countries, institutions, and authors are elucidated, and thematic mapping provides insight into the key research themes. Results: The analysis reveals a dynamic and expanding field, with an annual scientific growth rate of 12.25%. Notable contributions come from diverse sources, including North America, Europe, and Africa. High-impact journals such as JMIR mHealth and uHealth play a crucial role in disseminating research findings. African authors, including Lebelonyane R, Ford N, and Lockman S, feature prominently, reflecting a positive trend in diverse authorship. Co-citation analysis highlights influential manuscripts, with systematic reviews dominating the top-cited articles. Collaboration analysis underscores strategic partnerships globally, particularly involving the United States, Australia, South Africa, and the United Kingdom. Conclusion: This bibliometrics analysis provides a comprehensive overview of the digital health landscape in HIVST and linkage to care. It identifies key contributors, high-impact journals, and collaborative networks. The thematic map reveals nuanced research domains, including alcohol dependence, men's health, outcomes, and user acceptance. The findings offer insights for researchers, policymakers, and practitioners, guiding future directions in the evolving intersection of HIVST and digital health interventions.

Motivational Interviewing as an Intervention to Improve Antiretroviral Treatment Initiation Among People who Inject Drugs (PWID): A Pilot Study in Jakarta and Bandung, Indonesia

INTRODUCTION

Progress towards the 95-95-95 target among People Who Inject Drugs (PWID) with Human Immunodeficiency Virus (HIV) infection was considerably low. A behavioral approach, such as motivational interviewing (MI), has been recognized as an effective strategy for improving HIV treatment outcomes among PWID.

OBJECTIVE

This study aimed at assessing the impact of MI counselling to improve ARV initiation among HIV-positive PWID.

METHODS

A cohort design pilot study was performed, and participants were recruited using a convenience sampling technique. Participants were PWID with HIV who accessed healthcare facilities in two Indonesian cities. Selected participants were assigned to an intervention group and a control group. The intervention group followed MI counselling, while the control group received ART following the standard of care. The participants were assigned to each group based on their preferences. The data was collected between January 2018 and January 2019.

RESULTS

In total, 115 PWID with HIV participated in this study in the intervention (n = 30) and control (n = 85) groups. All but one intervention group's participants started ART, while 68/85 in the control group did so. Receiving MI counselling significantly contributed to ART initiation. In addition, the participants were followed-up until 12 months after ARV initiation. During this period, we found that similar proportions of participants in both groups discontinued the treatment, and only a small number achieved HIV viral suppression.

CONCLUSION

The positive effect of MI counselling on ART initiation provides insight into the possibility of its wider implementation. Further studies are needed to gain a deeper understanding of MI counselling and its effect on other outcomes of the HIV treatment cascade.

Scaling up delivery of HIV services in Africa through harnessing trends across global emerging innovations

Globally, innovations for HIV response present exciting opportunities to enhance the impact and cost-effectiveness of any HIV program. However, countries especially in the African region are not on equal footing to effectively harness some of the existing innovations to accelerate impact on HIV services delivery. This paper aims to add to the discourse on innovative solutions to support countries to make informed decisions related to technologies that can be adapted in different contexts to strengthen HIV programs. A scoping review which involved a search of innovations that can be used in response to the HIV epidemic was carried out between June 2021 and December 2022. The results showed that a high level of technological advancement occurred in the area of digital technologies and devices. Out of the 202 innovations, 90% were digital technologies, of which 34% were data collection and analytics, 45% were mobile based applications, and 12% were social media interventions. Only 10% fell into the category of devices, of which 67% were rapid diagnostic tools (RDTs) and 19% were drone-based technologies among other innovative tools. The study noted that most of the innovations that scaled relied on a strong ICT infrastructure backbone. The scoping review presents an opportunity to assess trends, offer evidence, and outline gaps to drive the adoption and adaptation of such technologies in Africa.

HIV Care Profiling and Delivery Status in the Mobile Health Clinics of eThekwini District in KwaZulu Natal, South Africa: A Descriptive Evaluation Study

Mobile health clinics (MHCs) serve as an alternative HIV care delivery method for the HIV-burdened eThekwini district. This study aimed to describe and profile the HIV care services provided by the MHCs through process evaluation. A descriptive cross-sectional quantitative evaluation study was performed on 137 MHCs using total population sampling. An online data collection method using a validated 50-item researcher-developed instrument was administered to professional nurses who are MHC team leaders, following ethical approval from the local university and departments of health. Descriptive statistics were used to analyze the data. The results described that HIV care services are offered in open spaces (43%), community buildings (37%), solid built buildings called health posts (15%), vehicles (9%), and tents (2%) with no electricity (77%), water (55%), and sanitation (64%). Adults (97%) are the main recipients of HIV care in MHCs (90%) offering antiretroviral therapy (95%). Staff, monitoring, and retaining care challenges were noted, with good linkage (91%) and referral pathways (n = 123.90%). In conclusion, the standardization and prioritization of HIV care with specific contextual practice guidelines are vital.

An mHealth Platform for People With HIV Receiving Care in Washington, District of Columbia: Qualitative Analysis of Stakeholder Feedback

BACKGROUND

HIV viral suppression and retention in care continue to be challenging goals for people with HIV in Washington, District of Columbia (DC). The PositiveLinks mobile app is associated with increased retention in care and viral load suppression in nonurban settings. The app includes features such as daily medication reminders, mood and stress check-ins, an anonymized community board for peer-to-peer social support, secure messaging to care teams, and resources for general and clinic-specific information, among other features. PositiveLinks has not been tailored or tested for this distinct urban population of people with HIV.

OBJECTIVE

This study aimed to inform the tailoring of a mobile health app to the needs of people with HIV and their providers in Washington, DC.

METHODS

We conducted a 3-part formative study to guide the tailoring of PositiveLinks for patients in the DC Cohort, a longitudinal cohort of >12,000 people with HIV receiving care in Washington, DC. The study included in-depth interviews with providers (n=28) at study clinics, focus groups with people with HIV enrolled in the DC Cohort (n=32), and a focus group with members of the DC Regional Planning Commission on Health and HIV (COHAH; n=35). Qualitative analysis used a constant comparison iterative approach; thematic saturation and intercoder agreement were achieved. Emerging themes were identified and grouped to inform an adaptation of PositiveLinks tailored for patients and providers.

RESULTS

Emerging themes for patients, clinic providers, and COHAH providers included population needs and concerns, facilitators and barriers to engagement in care and viral suppression, technology use, anticipated benefits, questions and concerns, and suggestions. DC Cohort clinic and COHAH provider interviews generated an additional theme: clinic processes. For patients, the most commonly discussed potential benefits included improved health knowledge and literacy (mentioned n=10 times), self-monitoring (n=7 times), and connection to peers (n=6 times). For providers, the most common anticipated benefits were improved communication with the clinic team (n=21), connection to peers (n=14), and facilitation of self-monitoring (n=11). Following data review, site principal investigators selected core PositiveLinks features, including daily medication adherence, mood and stress check-ins, resources, frequently asked questions, and the community board. Principal investigators wanted English and Spanish versions depending on the site. Two additional app features (messaging and documents) were selected as optional for each clinic site. Overall, 3 features were not deployed as not all participating clinics supported them.

CONCLUSIONS

Patient and provider perspectives of PositiveLinks had some overlap, but some themes were unique to each group. Beta testing of the tailored app was conducted (August 2022). This formative work prepared the team for a cluster randomized controlled trial of PositiveLinks' efficacy. Randomization of clinics to PositiveLinks or usual care occurred in August 2022, and the randomized controlled trial launched in November 2022.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/37748.

Peer Counselor Intervention for Reducing Mortality and/or Hospitalization in Adults With Hypertensive Urgency in Tanzania: A Pilot Study

BACKGROUND

Worldwide, people with hypertensive urgency experience high rates of hospitalization and death due to medication non-adherence. Interventions to improve medication adherence and health outcomes after hypertensive urgency are urgently needed.

METHODS

This prospective cohort assessed the effect of a peer counselor intervention-named Rafiki mwenye msaada-on the 1-year incidence of hospitalization and/or death among adults with hypertensive urgency in Mwanza, Tanzania. We enrolled 50 patients who presented with hypertensive urgency to 2 hospitals in Mwanza, Tanzania. All 50 patients received a Rafiki mwenye msaada an individual-level, time-limited case management intervention. Rafiki mwenye msaada aims to empower adult patients with hypertensive urgency to manage their high blood pressure. It consists of 5 sessions delivered over 3 months by a peer counselor. Outcomes were compared to historical controls.

RESULTS

Of the 50 patients (median age, 61 years), 34 (68%) were female, and 19 (38%) were overweight. In comparison to the historical controls, the intervention cohort had a significantly lower proportion of patients with a secondary level of education (22% vs. 35%) and health insurance (40% vs. 87%). Nonetheless, the 1-year cumulative incidence of hospitalization and/or death was 18% in the intervention cohort vs. 35% in the control cohort (adjusted Hazard Ratio, 0.48, 95% CI 0.24-0.97; P = 0.041). Compared to historical controls, intervention participants maintained higher rates of medication use and clinic attendance at both 3- and 6-months but not at 12 months. Of intervention participants who survived and remained in follow-up, >90% reported good medication adherence at all follow-up time points.

CONCLUSION

Our findings support the hypothesis that a peer counselor intervention may improve health outcomes among adults living with hypertensive urgency. A randomized clinical trial is needed to evaluate the intervention's effectiveness.

Strategies to improve antiretroviral therapy (ART) initiation and early engagement among men in sub-Saharan Africa: A scoping review of interventions in the era of universal treatment

OBJECTIVES

Men in sub-Saharan Africa (SSA) have lower rates of antiretroviral therapy (ART) initiation and higher rates of early default than women. Little is known about effective interventions to improve men's outcomes. We conducted a scoping review of interventions aimed to increase ART initiation and/or early retention among men in SSA since universal treatment policies were implemented.

METHODS

Three databases, HIV conference databases and grey literature were searched for studies published between January 2016 to May 2021 that reported on initiation and/or early retention among men. Eligibility criteria included: participants in SSA, data collected after universal treatment policies were implemented (2016-2021), quantitative data on ART initiation and/or early retention for males, general male population (not exclusively focused on key populations), intervention study (report outcomes for at least one non-standard service delivery strategy), and written in English.

RESULTS

Of the 4351 sources retrieved, 15 (reporting on 16 interventions) met inclusion criteria. Of the 16 interventions, only two (2/16, 13%) exclusively focused on men. Five (5/16, 31%) were randomised control trials (RCT), one (1/16, 6%) was a retrospective cohort study, and 10 (10/16, 63%) did not have comparison groups. Thirteen (13/16, 81%) interventions measured ART initiation and six (6/16, 37%) measured early retention. Outcome definitions and time frames varied greatly, with seven (7/16, 44%) not specifying time frames at all. Five types of interventions were represented: optimising ART services at health facilities, community-based ART services, outreach support (such as reminders and facility escort), counselling and/or peer support, and conditional incentives. Across all intervention types, ART initiation rates ranged from 27% to 97% and early retention from 47% to 95%.

CONCLUSIONS

Despite years of data of men's suboptimal ART outcomes, there is little high-quality evidence on interventions to increase men's ART initiation or early retention in SSA. Additional randomised or quasi-experimental studies are urgently needed.

Does a youth intern programme strengthen HIV service delivery in South Africa? An interrupted time-series analysis

INTRODUCTION

Since 2018, Youth Health Africa (YHA) has placed unemployed young adults at health facilities across South Africa in 1-year non-clinical internships to support HIV services. While YHA is primarily designed to improve employment prospects for youth, it also strives to strengthen the health system. Hundreds of YHA interns have been placed in programme (e.g. HIV testing and counselling) or administrative (e.g. data and filing) roles, but their impact on HIV service delivery has not been evaluated.

METHODS

Using routinely collected data from October 2017 to March 2020, we conducted an interrupted time-series analysis to explore the impact of YHA on HIV testing, treatment initiation and retention in care. We analysed data from facilities in Gauteng and North West where interns were placed between November 2018 and October 2019. We used linear regression, accounting for facility-level clustering and time correlation, to compare trends before and after interns were placed for seven HIV service indicators covering HIV testing, treatment initiation and retention in care. Outcomes were measured monthly at each facility. Time was measured as months since the first interns were placed at each facility. We conducted three secondary analyses per indicator, stratified by intern role, number of interns and region.

RESULTS

Based on 207 facilities hosting 604 interns, YHA interns at facilities were associated with significant improvements in monthly trends for numbers of people tested for HIV, newly initiated on treatment and retained in care (i.e. loss to follow-up, tested for viral load [VL] and virally suppressed). We found no difference in trends for the number of people newly diagnosed with HIV or the number initiating treatment within 14 days of diagnosis. Changes in HIV testing, overall treatment initiation and VL testing/suppression were most pronounced where there were programme interns and a higher number of interns; change in loss to follow-up was greatest where there were administrative interns.

CONCLUSIONS

Placing interns in facilities to support non-clinical tasks may improve HIV service delivery by contributing to improved HIV testing, treatment initiation and retention in care. Using youth interns as lay health workers may be an impactful strategy to strengthen the HIV response while supporting youth employment.

Impact of short message service and peer navigation on linkage to care and antiretroviral therapy initiation in South Africa

OBJECTIVE

We examine the efficacy of short message service (SMS) and SMS with peer navigation (SMS + PN) in improving linkage to HIV care and initiation of antiretroviral therapy (ART).

DESIGN

I-Care was a cluster randomized trial conducted in primary care facilities in North West Province, South Africa. The primary study outcome was retention in HIV care; this analysis includes secondary outcomes: linkage to care and ART initiation.

METHODS

Eighteen primary care clinics were randomized to automated SMS ( n  = 7), automated and tailored SMS + PN ( n  = 7), or standard of care (SOC; n  = 4). Recently HIV diagnosed adults ( n  = 752) were recruited from October 2014 to April 2015. Those not previously linked to care ( n  = 352) contributed data to this analysis. Data extracted from clinical records were used to assess the days that elapsed between diagnosis and linkage to care and ART initiation. Cox proportional hazards models and generalized estimating equations were employed to compare outcomes between trial arms, overall and stratified by sex and pregnancy status.

RESULTS

Overall, SMS ( n  = 132) and SMS + PN ( n  = 133) participants linked at 1.28 [95% confidence interval (CI): 1.01-1.61] and 1.60 (95% CI: 1.29-1.99) times the rate of SOC participants ( n  = 87), respectively. SMS + PN significantly improved time to ART initiation among non-pregnant women (hazards ratio: 1.68; 95% CI: 1.25-2.25) and men (hazards ratio: 1.83; 95% CI: 1.03-3.26) as compared with SOC.

CONCLUSION

Results suggest SMS and peer navigation services significantly reduce time to linkage to HIV care in sub-Saharan Africa and that SMS + PN reduced time to ART initiation among men and non-pregnant women. Both should be considered candidates for integration into national programs.

TRIAL REGISTRATION

NCT02417233, registered 12 December 2014; closed to accrual 17 April 2015.

HIV Continuum of Care Among People Who Inject Drugs in Iran: A Cross-sectional Study

ABSTRACT

People living with HIV who inject drugs may have lower access to treatment services. We aimed to assess the HIV continuum of care among people who inject drugs (PWID) in Iran. Data were collected from 2,663 PWID who were recruited via respondent-driven sampling from 11 cities of Iran between June 2019 and March 2020. Participants who tested positive for HIV infection were asked questions to calculate the status of HIV cascade of care. Of 95 PWID living with HIV, 67% were aware of their HIV status, 57% were linked to care service and initiated ART, 49% retained on ART, and only 15% had viral load less than 1,000 copies/ml. About half of the PWID diagnosed with HIV ever started ART and less than one in six were virally suppressed. Strategies to improve linkage to ART programs and ART retention may improve HIV care outcomes among PWID in Iran.

Trajectories of re-engagement: factors and mechanisms enabling patient return to HIV care in Zambia

INTRODUCTION

While disengagement from HIV care threatens the health of persons living with HIV (PLWH) and incidence-reduction targets, re-engagement is a critical step towards positive outcomes. Studies that establish a deeper understanding of successful return to clinical care among previously disengaged PLWH and the factors supporting re-engagement are essential to facilitate long-term care continuity.

METHODS

We conducted narrative, patient-centred, in-depth interviews between January and June 2019 with 20 PLWH in Lusaka, Zambia, who had disengaged and then re-engaged in HIV care, identified through electronic medical records (EMRs). We applied narrative analysis techniques, and deductive and inductive thematic analysis to identify engagement patterns and enablers of return.

RESULTS

We inductively identified five trajectories of care engagement, suggesting patterns in patient characteristics, experienced barriers and return facilitators that may aid intervention targeting including: (1) intermittent engagement;(2) mostly engaged; (3) delayed linkage after testing; (4) needs time to initiate antiretroviral therapy (ART); and (5) re-engagement with ART initiation. Patient-identified periods of disengagement from care did not always align with care gaps indicated in the EMR. Key, interactive re-engagement facilitators experienced by participants, with varied importance across trajectories, included a desire for physical wellness and social support manifested through verbal encouragement, facility outreach or personal facility connections and family instrumental support. The mechanisms through which facilitators led to return were: (1) the promising of living out one's life priorities; (2) feeling valued; (3) fostering interpersonal accountability; (4) re-entry navigation support; (5) facilitated care and treatment access; and (6) management of significant barriers, such as depression.

CONCLUSIONS

While preliminary, the identified trajectories may guide interventions to support re-engagement, such as offering flexible ART access to patients with intermittent engagement patterns instead of stable patients only. Further, for re-engagement interventions to achieve impact, they must activate mechanisms underlying re-engagement behaviours. For example, facility outreach that reminds a patient to return to care but does not affirm a patient's value or navigate re-entry is unlikely to be effective. The demonstrated importance of positive health facility connections reinforces a growing call for patient-centred care. Additionally, interventions should consider the important role communities play in fostering treatment motivation and overcoming practical barriers.

"They are gaining experience; we are gaining extra hands": a mixed methods study to assess healthcare worker perceptions of a novel strategy to strengthen human resources for HIV in South Africa

BACKGROUND

Lay health workers (LHWs) can support the HIV response by bridging gaps in human resources for health. Innovative strategies are needed to expand LHW programs in many low- and middle-income countries. Youth Health Africa (YHA) is a novel LHW approach implemented in South Africa that places young adults needing work experience in one-year non-clinical internships at health facilities to support HIV programs (e.g., as HIV testers, data clerks). While research suggests YHA can increase HIV service delivery, we need to understand healthcare worker perceptions to know if this is an acceptable and appropriate approach to strengthen human resources for health and healthcare delivery.

METHODS

We conducted a convergent mixed methods study to assess healthcare worker acceptance and perceived appropriateness of YHA as implemented in Gauteng and North West provinces, South Africa and identify issues promoting or hindering high acceptability and perceived appropriateness. To do this, we adapted the Johns Hopkins Measure of Acceptability and Appropriateness to survey healthcare workers who supervised interns, which we analyzed descriptively. In parallel, we interviewed frontline healthcare workers who worked alongside YHA interns and conducted an inductive, thematic analysis. We merged quantitative and qualitative results using the Theoretical Framework of Acceptability to understand what promotes or hinders high acceptance and appropriateness of YHA.

RESULTS

Sixty intern supervisors responded to the survey (91% response rate), reporting an average score of 3.5 for acceptability and 3.6 for appropriateness, on a four-point scale. Almost all 33 frontline healthcare workers interviewed reported the program to be highly acceptable and appropriate. Perceptions that YHA was mutually beneficial, easy to integrate into facilities, and helped facilities be more successful promoted a strong sense of acceptability/appropriateness amongst healthcare workers, but this was tempered by the burden of training interns and limited program communication. Overall, healthcare workers were drawn to the altruistic nature of YHA.

CONCLUSION

Healthcare workers in South Africa believed YHA was an acceptable and appropriate LHW program to support HIV service delivery because its benefits outweighed its costs. This may be an effective, innovative approach to strengthen human resources for HIV services and the broader health sector.

Self-transfers and factors associated with successful tracing among persons lost to follow-up from HIV care, Sheema District, Southwestern Uganda: retrospective medical records review, 2017-2021

BACKGROUND

Due to improved coverage and scale-up of antiretroviral therapy (ART), patients are increasingly transferring between ART-providing sites. Self-transfers may constitute a high proportion of patients considered lost to follow-up (LTFU), and if overlooked when reporting patients who have dropped out of HIV care, may result in an incorrect estimation of retention. We determined the prevalence of self-transfers, and successful tracing, and identified associated factors among people living with HIV (PLHIV) LTFU from care at public health facilities in Sheema District, Southwestern Uganda.

METHODS

We conducted a cross-sectional retrospective medical records review during February and March 2022. We included records of all PLHIV who were LTFU from 2017 to 2021, and who were registered at government-owned ART clinics in Sheema District. LTFU was considered for those who were not taking ART refills for a period of ≥ 3 months. We abstracted demographic and clinical data from medical records at the selected clinics. Participants were traced via phone calls or in-person to ascertain the outcomes of LTFU. We performed multivariate modified Poisson regression to identify factors associated with self-transfer, and successful tracing.

RESULTS

Overall, 740 patients were identified as LTFU from three ART-providing clinics; of these, 560 (76%) were self-transfers. The mean age was 30 (SD ± 10) years, and most (69%, n = 514) were female; the majority (87%, 641/740) were successfully traced. Age (adjusted prevalence ratio [aPR] = 1.13, 95% CI 1.01-1.25, P = 0.026 for those aged 18-30 years compared to > 30 years), female sex (aPR = 1.18, 95% CI 1.11-1.25, P < 0.001), and having WHO clinical stage 1-2 (aPR = 2.34, 95% CI 1.89-3.91, P < 0.001) were significantly associated with self-transfer. Presence of a phone contact in the patient's file (aPR = 1.10, 95% CI 1.01-1.90, P = 0.026) was associated with successful tracing of the patients considered LTFU.

CONCLUSION

Self-transfers accounted for the majority of patients recorded as LTFU, highlighting the need to account for self-transfers among patients considered LTFU, to accurately estimate retention in care. ART-providing facilities should regularly update contact information for PLHIV to enable successful tracing, in the event that the patients are LTFU. This calls for a health-tracking system that easily identifies self-transfers across ART-providing clinics using unique patient identifiers.

Effectiveness of linkage to care and prevention interventions following HIV self-testing: a global systematic review and meta-analysis protocol

INTRODUCTION

Early identification of persons living with HIV (PLWH) is crucial to institute timely treatment to prevent HIV-related morbidity and mortality. The convenience, flexibility and confidentiality of HIV self-testing enhance the acceptability of HIV testing and early detection of PLWH. However, persons who tested positive after a self-test are more likely to present late for treatment. This review seeks to evaluate the effectiveness of interventions to improve linkage to care and prevention after self-testing.

METHODS AND ANALYSIS

We will search PubMed, Embase, Web of Science, Cochrane Library, PsycInfo, Global Health Library, ClinicalTrials.gov and current controlled trials for all randomised and non-randomised studies published from 1 January 2010 to 31 July 2022 without language restriction. Two review authors will independently screen and select articles (based on the eligibility criteria for this review), extract data and assess the risk of bias in the included studies. Study-specific estimates will be converted to log risk ratios and weighted by the inverse of the variance of the log risk ratio before pooling into a fixed-effect model. The Cochrane's Q χ2 test and the I2 statistic will be used to assess and quantify heterogeneity in the included studies, respectively. The Egger's test and funnel plots will be used to assess publication bias. Sensitivity analysis will be conducted using leave-one-out analysis to assess the impact of outliers on the overall summary intervention effect.

ETHICS AND DISSEMINATION

No ethical clearance is needed for the current study as it will be based on already published articles. We will publish the findings of this study in international peer-reviewed journals and present them at conferences.

Efficiency of the EmERGE Pathway to provide continuity of care for Spanish people living with medically stable HIV

OBJECTIVE

Calculate the efficiency of the EmERGE Pathway of Care for medically stable people living with HIV at the Hospital Clínic-IDIBAPS, Barcelona, Spain.

METHODS

546 study participants were followed between 1st July 2016 and 30th October 2019 across three HIV outpatient clinics, but the virtual clinic was closed during the second year. Unit costs were calculated, linked to mean use outpatient services per patient year, one-year before and after the implementation of EmERGE. Costs were combined with primary and secondary outcomes.

RESULTS

Annual costs across HIV-outpatient services increased by 8%: €1073 (95%CI €999-€1157) to €1158 (95%CI €1084-€1238). Annual cost of ARVs was €7,557; total annual costs increased by 1% from €8430 (95%CI €8356-8514) to €8515 (95%CI €8441-8595). Annual cost for 433 participants managed in face-to-face (F2F) clinics decreased by 5% from €958 (95%CI 905-1018) to €904 (95%CI 863-945); participants transferred from virtual to F2F outpatient clinics (V2F) increased their annual cost by a factor of 2.2, from €115 (95%CI 94-139) to €251 (95%CI 219-290). No substantive changes were observed in primary and secondary outcomes.

CONCLUSION

EmERGE Pathway is an efficient and acceptable intervention. Increases in costs were caused by internal structural changes. The cost reduction observed in F2F clinics were off-set by the transfer of participants from the virtual to the F2F clinics due to the closure of the virtual clinic during the second year of the Study. Greater efficiencies are likely to be achieved by extending the use of the Pathway to other PLHIV.

Risk factors for late linkage to care and delayed antiretroviral therapy initiation amongst HIV infected adults in sub-Saharan Africa: a systematic review and meta-analyses

BACKGROUND

Late treatment initiation threatens the clinical and public health benefits of antiretroviral therapy (ART). Quantitative synthesises of the existing evidence related to this is lacking in sub-Saharan Africa (SSA), which would help ascertain the best evidence-based interventions. This review aimed to systematically synthesise the available literature on factors affecting linkage to care and ART initiation amongst HIV-infected adults in SSA.

METHODS

Systematic searches were undertaken on four databases to identify observational studies investigating factors affecting both HIV care outcomes amongst adults (age ≥19 years) in SSA, and were published between January 1, 2015 and June 1, 2021. RevMan-5 software was used to conduct meta-analyses and Mantel-Haenszel statistics to pool outcomes with 95% confidence interval and <0.05 level of significance.

RESULTS

Forty-six studies were included in the systematic review, of which 18 fulfilled requirements for meta-analysis. In both narrative review and meta-analyses, factors related to health care delivery, individual perception and sociodemographic circumstances were associated with late linkage to care and delays in ART initiation.

CONCLUSION

This review identified a range of risk factors for late linkage to care and delayed ART initiation amongst HIV-infected adults in SSA. We recommend implementation of patient-centred intervention approaches to alleviate these barriers.

Evidence-based service delivery interventions for testing, linking, treating, and retaining children and adolescents living with HIV in primary health care settings: Protocol for a systematic review

Background

At the end of 2019, there were about 2.8 million children and adolescents aged 0–19 living with HIV. In contrast to pregnant women and adults, service delivery for children and adolescents living with HIV continues to lag behind with regard to access to care, components of care delivery, treatment options, and clinical and immunologic outcomes.

Aim

The aim of this systematic review is to synthesize the evidence on the most effective interventions, models, programs, and strategies to optimize the delivery of services for the testing, linkage, treatment and retention of children and adolescents living with HIV globally.

Methods

This review protocol is registered at PROSPERO with Registration number: CRD42020209553. The systematic review will be conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis Protocols (PRISMA-P). We will use a comprehensive search strategy to search several bibliographic databases including MEDLINE, Embase, CINAHL, Cochrane Library, Global Health, and Psycinfo to identify relevant studies published in the last ten years (2010 to 2020). In addition, we will review cited and citing references of included studies. A pair of reviewers will independently screen titles, abstracts and full texts of articles, extract data from articles meeting inclusion criteria and perform quality assessments of the evidence collected. We will conduct a narrative synthesis of our findings, and if there are sufficient clinically similar studies available, we will conduct meta-analysis using a random-effects model.

Discussion

This review will provide evidence on service delivery models that have been evaluated in a range of settings to efficiently and effectively locate, link, treat and retain in care, children and adolescents living with HIV. The synthesized evidence will help guide national governments and health care providers in prioritizing and adopting evidence-based service delivery approaches for children and adolescents living with HIV.

Systematic review registration

PROSPERO CRD42020209553.

Evaluation of the Implementation and Effectiveness of a Mobile Health Intervention to Improve Outcomes for People With HIV in the Washington, DC Cohort: Study Protocol for a Cluster Randomized Controlled Trial

BACKGROUND

Gaps remain in achieving retention in care and durable HIV viral load suppression for people with HIV in Washington, DC (hereafter DC). Although people with HIV seeking care in DC have access to a range of supportive services, innovative strategies are needed to enhance patient engagement in this setting. Mobile health (mHealth) interventions have shown promise in reaching previously underengaged groups and improving HIV-related outcomes in various settings.

OBJECTIVE

This study will evaluate the implementation and effectiveness of a clinic-deployed, multifeature mHealth intervention called PositiveLinks (PL) among people with HIV enrolled in the DC Cohort, a longitudinal cohort of people with HIV receiving care in DC. A cluster randomized controlled trial will be conducted using a hybrid effectiveness-implementation design and will compare HIV-related outcomes between clinics randomized to PL versus usual care.

METHODS

The study aims are threefold: (1) We will perform a formative evaluation of PL in the context of DC Cohort clinics to test the feasibility, acceptability, and usability of PL and tailor the platform for use in this context. (2) We will conduct a cluster randomized controlled trial with 12 DC Cohort clinics randomized to PL or usual care (n=6 [50%] per arm) and measure the effectiveness of PL by the primary outcomes of patient visit constancy, retention in care, and HIV viral load suppression. We aim to enroll a total of 482 participants from DC Cohort clinic sites, specifically including people with HIV who show evidence of inconsistent retention in care or lack of viral suppression. (3) We will use the Consolidated Framework for Implementation Research (CFIR) and the Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) framework to measure implementation success and identify site, patient, provider, and system factors associated with successful implementation. Evaluation activities will occur pre-, mid-, and postimplementation.

RESULTS

Formative data collection was completed between April 2021 and January 2022. Preliminary mHealth platform modifications have been performed, and the first round of user testing has been completed. A preimplementation evaluation was performed to identify relevant implementation outcomes and design a suite of instruments to guide data collection for evaluation of PL implementation throughout the trial period. Instruments include those already developed to support DC Cohort Study activities and PL implementation in other cohorts, which required modification for use in the study, as well as novel instruments designed to complete data collection, as guided by the CFIR and RE-AIM frameworks.

CONCLUSIONS

Formative and preimplementation evaluations will be completed in spring 2022 when the trial is planned to launch. Specifically, comprehensive formative data analysis will be completed following data collection, coding, preliminary review, and synthesis. Corresponding platform modifications are ready for beta testing within the DC Cohort. Finalization of the platform for use in the trial will follow beta testing.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04998019; https://clinicaltrials.gov/ct2/show/NCT04998019.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/37748.

"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.

Assessing the Relationship Between HIV Quality of Care and Treatment Literacy on ART Adherence and Viral Suppression Among Female Sex Workers Living in the Dominican Republic

This study assessed the relationship between the quality of HIV care and treatment literacy on antiretroviral therapy (ART) adherence and viral suppression among female sex workers (FSWs) living with HIV (n = 211) in Santo Domingo, Dominican Republic. Multivariable logistic regression results indicate better patient-provider communication (AOR 1.04; 95% CI 1.01-1.07) and respectful treatment (AOR 2.17; 95% CI 1.09-4.32) increase the odds of viral suppression, while higher costs reduce both the odds of ART adherence (AOR 0.57, 95% CI 0.34- 0.95) and being virally suppressed (AOR 0.59, 95% CI 0.41-0.85). Greater treatment literacy was associated with an increased odds of ART adherence (AOR 4.15 for understanding of viral load; 95% CI 1.50-11.52) and viral suppression (AOR 2.75 for understanding of CD4 count; 95% CI 1.31-5.80). Findings support investments in treatment education, effective and respectful patient-provider communication, dignified care, and cost-support for associated HIV care costs to facilitate FSWs' pathway towards viral suppression.

HIV testing and linkage to care-A case of a mobile diagnostic and counseling service in Mbeya, Tanzania; A quantitative study

HIV-care programmes are faced with significant challenges in getting newly diagnosed People Living with Human Immunodeficiency Virus (PLHIV) linked to care despite massive investment in HIV prevention, treatment and care. This study assessed the performance of mobile HIV Testing and Counseling service (mHTC) in provision of HIV-testing and linkage to care of newly diagnosed PLHIV from Key and Vulnerable Populations (KVPs). A retrospective review of the records of 25,248 clients was extracted from the mHTC database from October-2016 to September-2018. Of 25,248 clients, 51.71% were in 25-45 years age group, 55.4% were males, 60.5% were married and 62.1% had primary level of education. The median age of clients was 31 (IQR: 23-42) years. Out of the clients tested, 800 (3.17%) were diagnosed HIV-positive. Positivity was high among females 450 (4%), age group 25-45 years 538 (4.12%), divorced 202 (7.41%) and clients with primary level of education 504 (3.21%). An association between HIV status and sex, age group, relationship status and level of education was observed (P<0001). Out of the 800 HIV-positive clients, 418 (52.30%) were successfully linked to care. Among the positive clients, 5/6 (83.33%) children below 15 years old, 238/450 (52.89%) females and 39/64 (60.94%) widows were successfully linked to care. In the multivariable log binomial regression model age of the clients was associated with successful linkage to care. The mHTC was able to reach KVP clients; overall linkage for both sexes was 52.30% below the recommended UNAIDS 90-90-90 target. Raising the need to address the challenges associated with linkage and specific care for KVPs as a subset of the general population. The mHTC has shown that it is feasible to improve the reach of KVP clients; however, further research is required to examine the quality of this service at the community level.

Attitudes towards and experiences with economic incentives for engagement in HIV care and treatment: Qualitative insights from a randomized trial in Kenya

Growing literature has shown heterogenous effects of conditional cash incentives (CCIs) on HIV care retention. The field lacks insights into reasons why incentives impact various patients in different ways-differences that may be due to variations in psychological and social mechanisms of effect. A deeper understanding of patients' perceptions and experiences of CCIs for retention may help to clarify these mechanisms. We conducted a qualitative study embedded in the ADAPT-R trial (NCT#02338739), a sequential multiple assignment randomized trial (SMART) that evaluated economic incentives to support retention in HIV care among persons living with HIV (PLHIV) initiating antiretroviral therapy in Kenya. Participants who attended their scheduled clinic visits received an incentive of approximately $4 each visit. Interviews were conducted between July 2016 and June 2017 with 39 participants to explore attitudes and experiences with economic incentives conditional on care engagement. Analyses revealed that incentives helped PLHIV prioritize care-seeking by alleviating transport barriers and food insecurity: "I decided to forgo [work] and attend clinic […] the voucher relieved me". Patients who borrowed money for care-seeking reported feeling relieved from the burden of indebtedness to others: "I borrow with confidence that I will pay after my appointment." Incentives fostered their autonomy, and enabled them to support others: "I used the money to buy some clothes and Pampers for the children." Participants who were intrinsically motivated to engage in care ("my life depends on the drugs, not the incentive"), and those who mistrusted researchers, reported being less prompted by the incentive itself. For patients not already prioritizing care-seeking, incentives facilitated care engagement through alleviating transport costs, indebtedness and food insecurity, and also supported social role fulfillment. Conditional cash incentives may be an important cue to action to improve progression through the HIV treatment cascade, and contribute to better care retention.

The Role of Alcohol-Related Behavioral Research in the Design of HIV Secondary Prevention Interventions in the Era of Antiretroviral Therapy: Targeted Research Priorities Moving Forward

HIV secondary prevention focuses on averting onward HIV transmission, which can be realized when people living with HIV enact requisite HIV care continuum-related behaviors to achieve viral suppression, and engage in condom-protected sex when virally unsuppressed. Alcohol has been detrimentally linked to all aspects of HIV secondary prevention, and although a growing number of behavioral interventions account for and address alcohol use within this realm, further efforts are needed to fully realize the potential of such initiatives. The present article proposes a series of targeted priorities to inform the future design, implementation, and evaluation of alcohol-related behavioral intervention research within the scope of HIV secondary prevention. These priorities and corresponding approaches account for the challenges of resource-constrained clinic environments; capitalize on technology; and address key comorbidities. This framework provides the foundation for a range of alcohol-related behavioral interventions that could potentially enhance global HIV secondary prevention efforts in the years ahead.

Factors associated with an interruption in treatment of people living with HIV in USAID-supported states in Nigeria: a retrospective study from 2000-2020

Background

Patient interruption of antiretroviral therapy (ART) continues to limit HIV programs’ progress toward epidemic control. Multiple factors have been associated with client interruption in treatment (IIT)— including age, gender, CD4 count, and education level. In this paper, we explore the factors associated with IIT in people living with HIV (PLHIV) in United States Agency for International Development (USAID)-supported facilities under the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) program in Nigeria.

Methods

We conducted cross-sectional analyses on data obtained from Nigeria’s National Data Repository (NDR), representing a summarized record of 573 630 ART clients that received care at 484 PEPFAR/USAID-supported facilities in 16 states from 2000–2020. IIT was defined as no clinical contact for 28 days or more after the last expected clinical contact. Univariate and multivariate logistic regression models were computed to explore the factors associated with IIT. The variables included in the analysis were sex, age group, zone, facility level, regimen line, multi-month dispensing (MMD), and viral load category.

Results

Of the 573 630 clients analysed in this study, 32% have been recorded as having interrupted treatment. Of the clients investigated, 66% were female (32% had interrupted treatment), 39% were aged 25–34 at their last ART pick-up date (with 32% of them interrupted treatment), 59% received care at secondary level facilities (37% interrupted treatment) and 38% were last receiving between three- to five-month MMD (with 10% of these interrupted treatment). Those less likely to interrupt ART were males (aOR = 0.91), clients on six-month MMD (aOR = 0.01), adults on 2^nd line regimen (aOR = 0.09), and paediatrics on salvage regimen (aOR = 0.02). Clients most likely to interrupt ART were located in the South West Zone (aOR = 1.99), received treatment at a tertiary level (aOR = 12.34) or secondary level facilities (aOR = 4.01), and had no viral load (VL) on record (aOR =10.02). Age group was not significantly associated with IIT.

Conclusions

Sex, zone, facility level, regimen line, MMD, and VL were significantly associated with IIT. MMD of three months and longer (especially six months) had better retention on ART than those on shorter MMD. Not having a VL on record was associated with a considerable risk of IIT.

Longitudinal analysis of sociodemographic, clinical and therapeutic factors of HIV-infected individuals in Kinshasa at antiretroviral therapy initiation during 2006-2017

Background

The benefits of antiretroviral therapy (ART) underpin the recommendations for the early detection of HIV infection and ART initiation. Late initiation (LI) of antiretroviral therapy compromises the benefits of ART both individually and in the community. Indeed, it promotes the transmission of infection and higher HIV-related morbidity and mortality with complicated and costly clinical management.

This study aims to analyze the evolutionary trends in the median CD4 count, the median time to initiation of ART, the proportion of patients with advanced HIV disease at the initiation of ART between 2006 and 2017 and their factors.

Methods and findings

HIV-positive adults (≥ 16 years old) who initiated ART between January 1, 2006 and December 31, 2017 in 25 HIV care facilities in Kinshasa, the capital of DRC, were eligible. The data were processed anonymously. LI is defined as CD4≤350 cells/μl and/or WHO clinical stage III or IV and advanced HIV disease (AHD), as CD4≤200 cells/μl and/or stage WHO clinic IV. Factors associated with advanced HIV disease at ART initiation were analyzed, irrespective of year of enrollment in HIV care, using logistic regression models.

A total of 7278 patients (55% admitted after 2013) with an average age of 40.9 years were included. The majority were composed of women (71%), highly educated women (68%) and married or widowed women (61%). The median CD4 was 213 cells/μl, 76.7% of patients had CD4≤350 cells/μl, 46.1% had CD4≤200 cells/μl, and 59% of patients were at WHO clinical stages 3 or 4. Men had a more advanced clinical stage (p <0.046) and immunosuppression (p<0.0007) than women.

Overall, 70% of patients started ART late, and 25% had AHD. Between 2006 and 2017, the median CD4 count increased from 190 cells/μl to 331 cells/μl (p<0.0001), and the proportions of patients with LI and AHD decreased from 76% to 47% (p< 0.0001) and from 18.7% to 8.9% (p<0.0001), respectively.

The median time to initiation of ART after screening for HIV infection decreased from 40 to zero months (p<0.0001), and the proportion of time to initiation of ART in the month increased from 39 to 93.3% (p<0.0001) in the same period.

The probability of LI of ART was higher in married couples (OR: 1.7; 95% CI: 1.3–2.3) (p<0.0007) and lower in patients with higher education (OR: 0.74; 95% CI: 0.64–0.86) (p<0.0001).

Conclusion

Despite increasingly rapid treatment, the proportions of LI and AHD remain high. New approaches to early detection, the first condition for early ART and a key to ending the HIV epidemic, such as home and work HIV testing, HIV self-testing and screening at the point of service, must be implemented.

Stakeholder efforts to mitigate antiretroviral therapy interruption among people living with HIV during the COVID-19 pandemic in China: a qualitative study

Introduction

The COVID‐19 pandemic has affected antiretroviral therapy (ART) continuity among people living with HIV (PLHIV) worldwide. We conducted a qualitative study to explore barriers to ART maintenance and solutions to ART interruption when stringent COVID‐19 control measures were implemented in China, from the perspective of PLHIV and relevant key stakeholders.

Methods

Between 11 February and 15 February 2020, we interviewed PLHIV, community‐based organization (CBO) workers, staff from centres for disease control and prevention (CDC) at various levels whose work is relevant to HIV care (CDC staff), HIV doctors and nurses and drug vendors from various regions in China. Semi‐structured interviews were conducted using a messaging and social media app. Challenges and responses relevant to ART continuity during the COVID‐19 pandemic were discussed. Themes were identified by transcript coding and mindmaps.

Results

Sixty‐four stakeholders were recruited, including 16 PLHIV, 17 CBO workers, 15 CDC staff, 14 HIV doctors and nurses and two drug vendors. Many CDC staff, HIV doctors and nurses responsible for ART delivery and HIV care were shifted to COVID‐19 response efforts. Barriers to ART maintenance were (a) travel restrictions, (b) inadequate communication and bureaucratic obstacles, (c) shortage in personnel, (d) privacy concerns, and (e) insufficient ART reserve. CBO helped PLHIV maintain access to ART through five solutions identified from thematic analysis: (a) coordination to refill ART from local CDC clinics or hospitals, (b) delivery of ART by mail, (c) privacy protection measures, (d) mental health counselling, and (e) providing connections to alternative sources of ART. Drug vendors contributed to ART maintenance by selling out‐of‐pocket ART.

Conclusions

Social and institutional disruption from COVID‐19 contributed to increased risk of ART interruption among PLHIV in China. Collaboration among key stakeholders was needed to maintain access to ART, with CBO playing an important role. Other countries facing ART interruption during current or future public health emergencies may learn from the solutions employed in China.

Stakeholder efforts to mitigate antiretroviral therapy interruption among people living with HIV during the COVID-19 pandemic in China: a qualitative study

INTRODUCTION

The COVID-19 pandemic has affected antiretroviral therapy (ART) continuity among people living with HIV (PLHIV) worldwide. We conducted a qualitative study to explore barriers to ART maintenance and solutions to ART interruption when stringent COVID-19 control measures were implemented in China, from the perspective of PLHIV and relevant key stakeholders.

METHODS

Between 11 February and 15 February 2020, we interviewed PLHIV, community-based organization (CBO) workers, staff from centres for disease control and prevention (CDC) at various levels whose work is relevant to HIV care (CDC staff), HIV doctors and nurses and drug vendors from various regions in China. Semi-structured interviews were conducted using a messaging and social media app. Challenges and responses relevant to ART continuity during the COVID-19 pandemic were discussed. Themes were identified by transcript coding and mindmaps.

RESULTS

Sixty-four stakeholders were recruited, including 16 PLHIV, 17 CBO workers, 15 CDC staff, 14 HIV doctors and nurses and two drug vendors. Many CDC staff, HIV doctors and nurses responsible for ART delivery and HIV care were shifted to COVID-19 response efforts. Barriers to ART maintenance were (a) travel restrictions, (b) inadequate communication and bureaucratic obstacles, (c) shortage in personnel, (d) privacy concerns, and (e) insufficient ART reserve. CBO helped PLHIV maintain access to ART through five solutions identified from thematic analysis: (a) coordination to refill ART from local CDC clinics or hospitals, (b) delivery of ART by mail, (c) privacy protection measures, (d) mental health counselling, and (e) providing connections to alternative sources of ART. Drug vendors contributed to ART maintenance by selling out-of-pocket ART.

CONCLUSIONS

Social and institutional disruption from COVID-19 contributed to increased risk of ART interruption among PLHIV in China. Collaboration among key stakeholders was needed to maintain access to ART, with CBO playing an important role. Other countries facing ART interruption during current or future public health emergencies may learn from the solutions employed in China.

Substance use and HIV stage at entry into care among people with HIV

BACKGROUND

Information regarding the impact of substance use on the timing of entry into HIV care is lacking. Better understanding of this relationship can help guide approaches and policies to improve HIV testing and linkage.

METHODS

We examined the effect of specific substances on stage of HIV disease at entry into care in over 5000 persons with HIV (PWH) newly enrolling in care. Substance use was obtained from the AUDIT-C and ASSIST instruments. We examined the association between early entry into care and substance use (high-risk alcohol, methamphetamine, cocaine/crack, illicit opioids, marijuana) using logistic and relative risk regression models adjusting for demographic factors, mental health symptoms and diagnoses, and clinical site.

RESULTS

We found that current methamphetamine use, past and current cocaine and marijuana use was associated with earlier entry into care compared with individuals who reported no use of these substances.

CONCLUSION

Early entry into care among those with substance use suggests that HIV testing may be differentially offered to people with known HIV risk factors, and that individuals with substances use disorders may be more likely to be tested and linked to care due to increased interactions with the healthcare system.

Exploring perceived effects from loss of PEPFAR support for outreach in Kenya and Uganda

Introduction

In 2015, the President’s Emergency Plan for AIDS Relief undertook policy shifts to increase efficiencies in its programming, including transitioning HIV/AIDS funding away from low burden areas. We examine the impact of these changes on HIV outreach in Kenya and Uganda.

Methods

Qualitative data collection was conducted as a part of a broader mixed-methods evaluation. Two rounds of facility-level case studies and national-level interviews were conducted in Kenya and Uganda, with health facility, sub-national and central Ministry of Health staff, HIV clients, and implementing partners.

Results

In both countries, the loss of outreach support affected community-based HIV/AIDS education, testing, peer support, and defaulter tracing.

Discussion

Loss of external support for outreach raises concerns for countries’ ability to reach the 90–90-90 UNAIDS target, as key linkages between vulnerable communities and health systems can be adversely affected.

Conclusion

Development partners should consider how to mitigate potential consequences of transition policies to prevent negative effects at the community level.

Costs of implementing community-based intervention for HIV testing in sub-Saharan Africa: a systematic review

BACKGROUND

Community-based interventions (CBIs) are interventions aimed at improving the well-being of people in a community. CBIs for HIV testing seek to increase the availability of testing services to populations that have been identified as at high risk by reaching them in homes, schools, or community centers. However, evidence for a detailed cost analysis of these community-based interventions in sub-Saharan Africa (SSA) is limited. We conducted a systematic review of the cost analysis of HIV testing interventions in SSA.

METHODS

Keyword search was conducted on SCOPUS, CINAHL, MEDLINE, PsycINFO, Web of Science, and Global Health databases. Three categories of key terms used were cost (implementation cost OR cost-effectiveness OR cost analysis OR cost-benefit OR marginal cost), intervention (HIV testing), and region (sub-Saharan Africa OR sub-Saharan Africa OR SSA). CBI studies were included if they primarily focused on HIV testing, was implemented in SSA, and used micro-costing or ingredients approach.

RESULTS

We identified 1533 citations. After screening, ten studies were included in the review: five from East Africa and five from Southern Africa. Two studies conducted cost-effectiveness analysis, and one study was a cost-utility analysis. The remainder seven studies were cost analyses. Four intervention types were identified: HIV self-testing (HIVST), home-based, mobile, and Provider Initiated Testing and Counseling. Commonly costed resources included personnel (n = 9), materials and equipment (n = 6), and training (n = 5). Cost outcomes reported included total intervention cost (n = 9), cost per HIV test (n = 9), cost per diagnosis (n = 5), and cost per linkage to care (n = 3). Overall, interventions were implemented at a higher cost than controls, with the largest cost difference with HIVST compared to facility-based testing.

CONCLUSION

To better inform policy, there is an urgent need to evaluate the costs associated with implementing CBIs in SSA. It is important for cost reports to be detailed, uniform, and informed by economic evaluation guidelines. This approach minimizes biases that may lead decision-makers to underestimate the resources required to scale up, sustain, or reproduce successful interventions in other settings. In an evolving field of implementation research, this review contributes to current resources on implementation cost studies.

The effectiveness of peer-support for people living with HIV: A systematic review and meta-analysis

BACKGROUND

The practice of involving people living with HIV in the development and provision of healthcare has gained increasing traction. Peer-support for people living with HIV is assistance and encouragement by an individual considered equal, in taking an active role in self-management of their chronic health condition. The objective of this systematic review was to assess the effects of peer-support for people living with HIV.

METHODS

We conducted a systematic review in accordance with international guidelines. Following systematic searches of eight databases until May 2020, two reviewers performed independent screening of studies according to preset inclusion criteria. We conducted risk of bias assessments and meta-analyses of the available evidence in randomised controlled trials (RCTs). The certainty of the evidence for each primary outcome was evaluated with the Grading of Recommendations Assessment, Development, and Evaluation system.

RESULTS

After screening 219 full texts we included 20 RCTs comprising 7605 participants at baseline from nine different countries. The studies generally had low risk of bias. Main outcomes with high certainty of evidence showed modest, but superior retention in care (Risk Ratio [RR] 1.07; Confidence Interval [CI] 95% 1.02-1.12 at 12 months follow-up), antiretroviral therapy (ART) adherence (RR 1.06; CI 95% 1.01-1.10 at 3 months follow-up), and viral suppression (Odds Ratio up to 6.24; CI 95% 1.28-30.5 at 6 months follow-up) for peer-support participants. The results showed that the current state of evidence for most other main outcomes (ART initiation, CD4 cell count, quality of life, mental health) was promising, but too uncertain for firm conclusions.

CONCLUSIONS

Overall, peer-support with routine medical care is superior to routine clinic follow-up in improving outcomes for people living with HIV. It is a feasible and effective approach for linking and retaining people living with HIV to HIV care, which can help shoulder existing services.

TRIAL REGISTRATION

CRD42020173433.

Intersectional Stigma Among People Transitioning From Incarceration to Community-Based HIV Care in Gauteng Province, South Africa

People transitioning from incarceration to community-based HIV care experience HIV stigma, incarceration stigma, and the convergence of these stigmas with social inequities. The objective of this study is to understand intersectional stigma among people returning from incarceration with HIV in Gauteng Province, South Africa. Qualitative interviews were conducted with 42 study participants. We analyzed transcript segments and memos from these interviews. Our results showed that anticipated HIV stigma increased participants' difficulty with disclosure and treatment collection. Incarceration stigma, particularly the mark of a criminal record, decreased socioeconomic stability in ways that negatively affected medication adherence. These stigmas converged with stereotypes that individuals were inherently criminal "bandits." Male participants expressed concerns that disclosing their HIV status would lead others to assume they had engaged in sexual activity with men while incarcerated. AIDS education and prevention efforts will require multilevel stigma interventions to improve HIV care outcomes.

Performance characteristics of an instrument-free point-of-care CD4 test (VISITECT®CD4) for use in resource-limited settings

Objective

CD4+ T lymphocyte count remains the most common biomarker of immune status and disease progression in human immunodeficiency virus (HIV)-positive individuals. VISITECT®CD4 is an instrument-free, low-cost point-of-care CD4 test with a cut-off of 350 CD4 cells/μL. This study aimed to evaluate VISITECT®CD4 test's diagnostic accuracy.

Methods

Two hundred HIV-positive patients attending a tertiary HIV centre in South India were recruited. Patients provided venous blood for reference and VISITECT®CD4 tests. An additional finger-prick blood sample was obtained for VISITECT®CD4. VISITECT®CD4's diagnostic performance in identifying individuals with CD4 counts ≤350 cells/μL was assessed by calculating sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) taking flow cytometry as the reference.

Results

The overall agreement between VISITECT®CD4 and flow cytometry was 89.5% using venous blood and 81.5% using finger-prick blood. VISITECT®CD4 showed better performance using venous blood [sensitivity: 96.6% (95% confidence interval: 92.1%–98.9%), specificity: 70.9% (57.1%–82.4%), PPV: 89.7% (83.9%–94.0%) and NPV: 88.6% (75.4%–96.2%)] than using finger-prick blood [sensitivity: 84.8% (77.9%–90.2%), specificity: 72.7% (59.0%–83.9%), PPV: 89.1% (82.7%–93.8%) and NPV: 64.5% (51.3%–76.3%)].

Conclusion

VISITECT®CD4 performed well using venous blood, demonstrating its potential utility in decentralization of CD4 testing services in resource-constrained settings.

Ethics and the treatment as prevention strategy among transgender women living with HIV in Argentina

While numerous ethical concerns have been voiced regarding HIV service scale-up strategies targeting key populations, few studies have examined these from the perspective of affected groups. This study therefore sought to understand transgender women's experiences and perspectives of targeted HIV services scale-up in the context of Argentina's Treatment as Prevention strategy. In 2016, 25 purposively selected transgender women living with HIV were interviewed by a peer research associate. Interviews were audio recorded, transcribed verbatim and analysed using participatory coding techniques. Findings suggest that procedures around informed consent, including the provision of full information in lay language and voluntariness, were lacking both pre- and post-HIV test. Further, many transgender women felt disrespected and disregarded by healthcare workers. While the majority of participants were unaware of Treatment as Prevention, once explained, most felt the approach was ethical overall, and helped improve equity in HIV service access. Study findings offer several community-driven suggestions to support patient rights and the ethical scale-up of HIV services for transgender women in Buenos Aires, including the need for training in and the provision of non-judgemental, gender-affirmative care and the inclusion of peer-navigators.

The Treatment Ambassador Program: A Highly Acceptable and Feasible Community-Based Peer Intervention for South Africans Living with HIV Who Delay or Discontinue Antiretroviral Therapy

We conducted a novel pilot randomized controlled trial of the Treatment Ambassador Program (TAP), an 8-session, peer-based, behavioral intervention for people with HIV (PWH) in South Africa not on antiretroviral therapy (ART). PWH (43 intervention, 41 controls) completed baseline, 3- and 6-month assessments. TAP was highly feasible (90% completion), with peer counselors demonstrating good intervention fidelity. Post-intervention interviews showed high acceptability of TAP and counselors, who supported autonomy, assisted with clinical navigation, and provided psychosocial support. Intention-to-treat analyses indicated increased ART initiation by 3 months in the intervention vs. control arm (12.2% [5/41] vs. 2.3% [1/43], Fisher exact p-value = 0.105; Cohen's h = 0.41). Among those previously on ART (off for > 6 months), 33.3% initiated ART by 3 months in the intervention vs. 14.3% in the control arm (Cohen's h = 0.45). Results suggest that TAP was highly acceptable and feasible among PWH not on ART.

Healthy Choices Intervention is Associated with Reductions in Stigma Among Youth Living with HIV in the United States (ATN 129)

Considering the lack of validated stigma reduction interventions for youth living with HIV (YLWH), we evaluated effects of the Healthy Choices intervention on HIV-related stigma among YLWH. We analyzed data from the Adolescent Medicine Trials Network protocol 129, multi-site randomized controlled trial, applying latent growth curve modeling with two linear slopes estimating changes in Berger's Stigma Scale pre-intervention, 16, 28, and 52 weeks post-intervention, as well as the trajectory of stigma scores over the follow-up period (N = 183). Expected value for the growth intercept was statistically significant (Bintercept = 2.53; 95% CI 2.32, 2.73; p < 0.001), as were differences in the change from baseline to 16-week follow-up (Bintercept slope1 = - 0.02; 95% CI - 0.04, 0.01; p = 0.034). Expected value of the slope factor measuring growth over the follow-up period was non-significant suggesting that stigma scores were stable from 28 to 52 weeks. Our findings warrant replication and additional research comparing effects of this intervention to counterfactual controls.

Patient Perspectives and Willingness to Accept Incentives for Tuberculosis Diagnostic Evaluation in Uganda

OBJECTIVES

We assessed attitudes and perceptions and willingness to accept (WTA) varying incentive structures for completing tuberculosis (TB) diagnostic evaluation among patients in Uganda.

METHODS

We surveyed 177 adult patients undergoing TB evaluation at 10 health centers between September 2018 and March 2019. We collected household sociodemographic information and assessed attitudes and perceptions of incentives. We surveyed patients regarding their willingness to complete TB diagnostic evaluation in exchange for incentives ranging in value from 500 Ugandan shillings (USh) to 25 000USh (~$0.15-$6.75). We compared associations between WTA and patient characteristics using ordered logistic regression.

RESULTS

Participant willingness to return to the health center to complete TB diagnostic evaluation increased proportionally with incentive amount. The median participant accepted between 2000 and 5000 USh. Cash (52%) and transportation vouchers (34%) were the most popular incentive types. Half of respondents preferred unconditional incentives; for a multiday evaluation, 84% preferred conditioning incentive receipt upon returning to the health center. In multivariate models, we found the pairwise difference between the third and lowest income quartile (aOR = 2.38, 95% CI: 1.20-4.69; P = .01), younger age, and difficulty returning to the health center to be significantly associated with WTA higher incentive thresholds.

CONCLUSIONS

In Uganda, incentives such as cash transfers or transportation vouchers are an acceptable intervention for facilitating adherence to TB diagnostic evaluation. Household income is associated with preferred incentive structure and amount, especially for those at the cusp of the poverty threshold who are more likely to prefer unconditional and higher valued incentives. Targeted and context-specific socioeconomic supports for at-risk patients are needed to optimize outcomes.