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Thurman TR, Luckett B, Zani B, Nice J, Taylor TM. Can Support Groups Improve Treatment Adherence and Reduce Sexual Risk Behavior among Young People Living with HIV? Results from a Cohort Study in South Africa. Trop Med Infect Dis 2024; 9:162. [PMID: 39058204 PMCID: PMC11281618 DOI: 10.3390/tropicalmed9070162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Revised: 06/25/2024] [Accepted: 07/08/2024] [Indexed: 07/28/2024] Open
Abstract
Adolescents and young adults living with HIV (AYLHIV) in sub-Saharan Africa experience poorer HIV outcomes than adults, including lower ART adherence and virologic suppression. They also have high rates of unprotected sex, increasing the risk of adverse sexual health outcomes and onward transmission. This one-arm, pre-post study investigates a structured 14-session support group aiming to boost treatment adherence and sexual protective behavior for AYLHIV in South Africa. Logistic and Poisson regression analyses were performed on self-reported pre- and post-intervention survey data collected approximately 7.5 months apart from a cohort of 548 AYLHIV. Participants were significantly more likely to report at least 95% adherence at follow-up and rate their health as "good;" they also demonstrated greater treatment knowledge and had fewer absences from school overall and due to illness. Among sexually active AYLHIV, contraception use at last sex increased significantly, while condom use did not. Effects were small, and greater programmatic emphasis on adherence and multifaceted service packages is likely necessary to promote viral suppression. Nonetheless, the intervention addresses an important gap in service provision for AYLHIV in South Africa. Findings denote the potential for incorporating care and treatment components into sexual and reproductive health interventions tailored for AYLHIV.
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Affiliation(s)
- Tonya R. Thurman
- Tulane International, Cape Town 7806, South Africa
- Highly Vulnerable Children Research Center, Department of International Health and Sustainable Development, School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA 70112, USA
| | - Brian Luckett
- Highly Vulnerable Children Research Center, Department of International Health and Sustainable Development, School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA 70112, USA
| | - Babalwa Zani
- Tulane International, Cape Town 7806, South Africa
- Highly Vulnerable Children Research Center, Department of International Health and Sustainable Development, School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA 70112, USA
| | - Johanna Nice
- Highly Vulnerable Children Research Center, Department of International Health and Sustainable Development, School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA 70112, USA
| | - Tory M. Taylor
- Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC 27516, USA;
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Saura-Lázaro A, Augusto O, Fernández-Luis S, López-Varela E, Fuente-Soro L, Bila D, Tovela M, Macuacua N, Vaz P, Couto A, Bruno C, Naniche D. HIV care retention in three multi-month ART dispensing: a retrospective cohort study in Mozambique. AIDS 2024; 38:1402-1411. [PMID: 38652496 PMCID: PMC11216376 DOI: 10.1097/qad.0000000000003913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 03/14/2024] [Accepted: 03/21/2024] [Indexed: 04/25/2024]
Abstract
OBJECTIVE Evaluate the effect of three multimonth dispensing (3MMD) of antiretroviral therapy (ART) on HIV care retention in southern Mozambique. DESIGN Retrospective cohort study. METHODS We analyzed routine health data from people with HIV (PWH) aged 10 years old and older who started ART between January 2018 and March 2021. Individuals were followed until December 2021. Cox proportional-hazards models were used to compare attrition (lost to follow-up, death, and transfer out) between 3MMD and monthly ART dispensing. Results were stratified by time on ART before 3MMD enrolment: 'early enrollers' (<6 months on ART) and 'established enrollers' (≥6 months on ART), and age groups: adolescents and youth (AYLHIV) (10-24 years) and adults (≥25 years). RESULTS We included 7378 PWH (25% AYLHIV, 75% adults), with 59% and 62% enrolled in 3MMD, respectively. Median follow-up time was 11.3 [interquartile range (IQR): 5.7-21.6] months for AYLHIV and 10.2 (IQR: 4.8-20.9) for adults. Attrition was lower in PWH enrolled in 3MMD compared with monthly ART dispensing, in both established (aHR AYLHIV = 0.65; 95% CI: 0.54-0.78 and aHR adults = 0.50; 95% confidence interval (CI): 0.44-0.56) and early enrollers (aHR AYLHIV = 0.70; 95% CI: 0.58-0.85 and aHR adults = 0.63; 95% CI: 0.57-0.70). Among individuals in 3MMD, male gender (aHR = 1.30; 95% CI: 1.18-1.44) and receiving care in a medium-volume/low-volume healthcare facility (aHR = 1.18; 95% CI: 1.03-1.34) increased attrition risk. Conversely, longer ART time before 3MMD enrolment (aHR = 0.93; 95% CI: 0.92-0.94 per 1 month increase) and age at least 45 years (aHR = 0.77, 95% CI: 0.67-0.89) reduced risk of attrition. CONCLUSION 3MMD improves retention in care compared with monthly dispensing among established and early enrollers, although to a lesser extent among the latter.
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Affiliation(s)
- Anna Saura-Lázaro
- ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - Orvalho Augusto
- Centro de Investigação em Saúde de Manhiça (CISM)
- Faculdade de Medicina, Universidade Eduardo Mondlane, Maputo, Mozambique
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Sheila Fernández-Luis
- ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
- Centro de Investigação em Saúde de Manhiça (CISM)
| | - Elisa López-Varela
- ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
- Centro de Investigação em Saúde de Manhiça (CISM)
| | - Laura Fuente-Soro
- ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
- Centro de Investigação em Saúde de Manhiça (CISM)
| | - Dulce Bila
- Fundação Ariel Glaser Contra o SIDA Pediatrico
| | | | | | - Paula Vaz
- Fundação Ariel Glaser Contra o SIDA Pediatrico
| | - Aleny Couto
- Programa Nacional de Controle de HIV/SIDA, Ministério da Saúde
| | - Carmen Bruno
- Direcção Provincial de Saúde, Maputo, Mozambique
| | - Denise Naniche
- ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
- Centro de Investigação em Saúde de Manhiça (CISM)
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Zani B, Luckett B, Thurman TR. COVID-19 pandemic stressors, familial discord, and anxiety among adolescents living with HIV in South Africa: pathways to non-adherence. AIDS Care 2024; 36:137-144. [PMID: 38301123 DOI: 10.1080/09540121.2024.2308025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 01/10/2024] [Indexed: 02/03/2024]
Abstract
Adolescents living with HIV (ALHIV) have poorer adherence to antiretroviral treatment (ART). This study investigates the interconnectivity of stressors induced by the COVID-19 pandemic, anxiety and family dynamics on adolescents' adherence to ART. A telephone survey was conducted among 196 South African ALHIV previously enrolled in support groups. Generalized structural equations modeling was used to understand how pandemic-related stressors affected ART adherence. Respondents reported experiencing life stressors since the implementation of COVID-19 restrictions, including doing worse at school (32%), loss of household income (44%) and less food available (38%). Forty-two percent reported greater verbal aggression from adults at home and 60% experienced anxiety. The structural equations model demonstrated a direct path from experiencing life stressors to increased verbal aggression from caregivers, which led to anxiety and ultimately, poorer ART adherence. Each stressor experienced increased the odds of experiencing verbal aggression by 51% (OR=1.51, 95%CI=1.14-2.00) which, in turn, increased the odds of having anxiety four-fold (OR=4.1, 95%C =2.16-7.76). Anxiety was associated with a 74% reduction in the odds of being fully ART adherent (OR=0.26, 95%CI=0.08-0.81). COVID-19-induced stressors exacerbated the mental and physical vulnerability of ALHIV. Findings elucidate how both discord at home and anxiety can result in poorer ART adherence.
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Affiliation(s)
- Babalwa Zani
- Tulane International, Cape Town, South Africa
- Highly Vulnerable Children Research Center, Cape Town, South Africa
| | - Brian Luckett
- Tulane International, Cape Town, South Africa
- Highly Vulnerable Children Research Center, Cape Town, South Africa
- School of Public Health and Tropical Medicine, Department of International Health and Sustainable Development, Tulane University, New Orleans, LA, USA
| | - Tonya R Thurman
- Tulane International, Cape Town, South Africa
- Highly Vulnerable Children Research Center, Cape Town, South Africa
- School of Public Health and Tropical Medicine, Department of International Health and Sustainable Development, Tulane University, New Orleans, LA, USA
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Bassett IV, Yan J, Govere S, Khumalo A, Shazi Z, Nzuza M, Aung T, Rahman K, Zionts D, Dube N, Tshabalala S, Bogart LM, Parker RA. Does type of antiretroviral therapy pick-up point influence 12-month virologic suppression in South Africa? AIDS Care 2024:1-10. [PMID: 38861653 DOI: 10.1080/09540121.2024.2361817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 05/24/2024] [Indexed: 06/13/2024]
Abstract
We assessed the impact of community- versus clinic-based medication pick-up on rates of virologic suppression in an observational cohort of adults on ART enrolled in a decentralized antiretroviral therapy program (CCMDD) in South Africa. Participants either attended clinics where they were given the choice to pick up ART in community venues or traditional clinics, or clinics where this pathway was assigned. Among 1856 participants, 977 (53%) opted for community ART pick-up at enrollment, and 1201 (86%) were virologically suppressed at one year. Because of missing data on virologic suppression, primary results are based on a model incorporating multiple imputation. In addition to age and gender, distance from clinic and year of HIV diagnosis were included in the multivariable model. There was no difference in opting for clinic- vs. community-based pick-up with regard to achieving 12-month virologic suppression (aRR 1.02, 95% CI 0.98-1.05) in clinics offering choice. There was no impact of assigning all participants to an external pick-up point (aRR 1.00, 95% CI 0.95-1.06), but virologic suppression was reduced in the clinic that assigned participants to clinic pick-up (aRR 0.87, 95% CI 0.81-0.92). These results suggest that provision of community-based ART has not reduced continued virologic suppression in the population enrolled in the CCMDD program.
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Affiliation(s)
- Ingrid V Bassett
- Massachusetts General Hospital, Division of Infectious Diseases, Boston, MA, USA
- Massachusetts General Hospital, Medical Practice Evaluation Center, Boston, MA, USA
- Center for AIDS Research (CFAR), Harvard University, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Africa Health Research Institute, Durban, South Africa
| | - Joyce Yan
- Massachusetts General Hospital, Biostatistics Center, Boston, MA, USA
| | | | | | - Zinhle Shazi
- AIDS Healthcare Foundation, Durban, South Africa
| | | | - Taing Aung
- Massachusetts General Hospital, Medical Practice Evaluation Center, Boston, MA, USA
| | - Kashfia Rahman
- Massachusetts General Hospital, Medical Practice Evaluation Center, Boston, MA, USA
| | - Dani Zionts
- Massachusetts General Hospital, Medical Practice Evaluation Center, Boston, MA, USA
| | - Nduduzo Dube
- AIDS Healthcare Foundation, Durban, South Africa
| | | | | | - Robert A Parker
- Center for AIDS Research (CFAR), Harvard University, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Massachusetts General Hospital, Biostatistics Center, Boston, MA, USA
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Shigayeva A, Gcwensa N, Ndlovu CD, Ntumase N, Sabela S, Ohler L, Trivino-Duran L, Kamara EF, Hlophe K, Isaakidis P, Van Cutsem G. Retention on ART and viral suppression among patients in alternative models of differentiated HIV service delivery in KwaZulu-Natal, South Africa. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000336. [PMID: 36962695 PMCID: PMC10021436 DOI: 10.1371/journal.pgph.0000336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 11/10/2022] [Indexed: 06/18/2023]
Abstract
Differentiated models of HIV care (DMOC) aim to improve health care efficiency. We describe outcomes of five DMOC in KwaZulu-Natal, South Africa: facility adherence clubs (facility AC) and community adherence clubs (community AC), community antiretroviral treatment (ART) groups (CAG), spaced fast lane appointments (SFLA), and community pick up points (PuP). This retrospective cohort study included 8241 eligible patients enrolled into DMOC between 1/1/2012 and 31/12/2018. We assessed retention in DMOC and on ART, and viral load suppression (<1000 copies/mL). Kaplan-Meier techniques were applied to describe crude retention. Mixed effects parametric survival models with Weibull distribution and clustering on health center and individual levels were used to assess predictors for ART and DMOC attrition, and VL rebound (≥1000 copies/mL). Overall DMOC retention was 85%, 80%, and 76% at 12, 24 and 36 months. ART retention at 12, 24 and 36 months was 96%, 93%, 90%. Overall incidence rate of VL rebound was 1.9 episodes per 100 person-years. VL rebound rate was 4.9 episodes per 100 person-years among those enrolled in 2012-2015, and 0.8 episodes per 100 person-years among those enrolled in 2016-2018 (RR 0.12; 95% CI, 0.09-0.15, p<0.001). Prevalence of confirmed virological failure was 0.6% (38/6113). Predictors of attrition from DMOC and from ART were male gender, younger age, shorter duration on ART before enrollment. Low level viremia (>200-399 copies/mL) was associated with higher hazards of VL rebound and attrition from ART. Concurrent implementation of several DMOC in a large ART program is feasible and can achieve sustained retention on ART and VL suppression.
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Affiliation(s)
| | - Ntombi Gcwensa
- Médecins Sans Frontières—South Africa, Eshowe, South Africa
| | | | | | | | - Liesbet Ohler
- Médecins Sans Frontières—South Africa, Eshowe, South Africa
| | | | | | | | - Petros Isaakidis
- Southern African Medical Unit, Médecins Sans Frontières, Cape Town, South Africa
- Clinical and Molecular Epidemiology Unit, Department of Hygiene and Epidemiology, University of Ioannina School of Medicine, Ioannina, Greece
| | - Gilles Van Cutsem
- Southern African Medical Unit, Médecins Sans Frontières, Cape Town, South Africa
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, South Africa
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6
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Virologic outcomes after early referral of stable HIV-positive adults initiating ART to community-based adherence clubs in Cape Town, South Africa: A randomised controlled trial. PLoS One 2022; 17:e0277018. [PMCID: PMC9665366 DOI: 10.1371/journal.pone.0277018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 10/17/2022] [Indexed: 11/16/2022] Open
Abstract
Background
Differentiated service delivery (DSD) models are recommended for stable people living with HIV on antiretroviral therapy (ART) but there are few rigorous evaluations of patient outcomes.
Methods
Adherence clubs (ACs) are a form of DSD run by community health workers at community venues with 2–4 monthly ART refills and annual nurse assessments). Clinic-based care involves 2-monthly ART refills and 4-monthly nurse/doctor assessments. We compared virologic outcomes in stable adults randomised to ACs at four months post-ART initiation to those randomised to primary health care (PHC) ART clinics through 12 months on ART in Cape Town, South Africa (NCT03199027). We hypothesised that adults randomised to ACs would be more likely to be virally suppressed at 12 months post-ART initiation, versus adults randomised to continued PHC care. We enrolled consecutive adults on ART for 3–5 months who met local DSD [‘adherence clubs’ (AC)] eligibility (clinically stable, VL<400 copies/mL). The primary outcome was VL<400 copies/mL at 12 months on ART.
Results
Between January 2017 and April 2018, 220 adults were randomised (mean age 35 years; 67% female; median ART duration 18 weeks); 85% and 94% of participants randomised to ACs and PHCs attended their first service visit on schedule respectively. By 12 months on ART, 91% and 93% randomised to ACs and PHCs had a VL<400 copies/mL, respectively. In a binomial model adjusted for age, gender, previous ART use and nadir CD4 cell count, there was no evidence of superiority of ACs compared to clinic-based care (RD, -2.42%; 95% CI, -11.23 to 6.38). Findings were consistent when examining the outcome at a threshold of VL <1000 copies/mL.
Conclusion
Stable adults referred to DSDs at 4 months post-ART initiation had comparable virologic outcomes at 12 months on ART versus PHC clinics, with no evidence of superiority. Further research on long-term outcomes is required.
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Christ B, van Dijk JH, Nyandoro TY, Reichmuth ML, Kunzekwenyika C, Chammartin F, Egger M, Wringe A, Ballif M. Availability and experiences of differentiated antiretroviral therapy delivery at HIV care facilities in rural Zimbabwe: a mixed-method study. J Int AIDS Soc 2022; 25:e25944. [PMID: 36008925 PMCID: PMC9411726 DOI: 10.1002/jia2.25944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 05/20/2022] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION Zimbabwe adopted differentiated HIV care policies in 2015 to promote client-centred care and relieve strain on health facilities. We examined the availability, experiences and perceptions of differentiated antiretroviral therapy (ART) delivery in rural Zimbabwe following the policy adoption. METHODS We undertook a cross-sectional mixed methods study in all the 26 facilities providing HIV care in a rural district in Zimbabwe. We collected quantitative data about ART delivery and visit durations from 31 healthcare providers and a purposive stratified sample of 378 clients obtaining ART either through routine care or differentiated ART delivery models. We performed 26 semi-structured interviews among healthcare providers and seven focus group discussions (FGDs) among clients to elicit their perceptions and experiences of ART delivery. Data were collected in 2019, with one follow-up FGD in 2021. We analysed the transcripts thematically, with inductive coding, to identify emerging themes. RESULTS Twenty facilities (77%) offered at least one differentiated ART delivery models, including community ART refill groups (CARGs; 13 facilities, 50%), fast-track refill (8, 31%), family refill (6, 23%) or club refill (1, 4%). Thirteen facilities (50%) offered only one model. The median visit duration was 28 minutes (interquartile range [IQR]: 16-62). Participants in fast-track had the shortest visit durations (18 minutes, IQR: 11-24). Confidentiality and disclosure of HIV status, travelling long distances, travel costs and waiting times were the main issues influencing clients' views on differentiated ART delivery. Fast-track refill was perceived as the preferred model of clients for its limited involuntary disclosure and efficiency. In contrast, group- and community-based refill models reduced travel costs but were felt to be associated with involuntary disclosure of HIV status, which could discourage clients. Healthcare providers also experienced an additional workload when offering facility-based group models, such as CARGs. CONCLUSIONS Differentiated ART delivery models were widely available in this rural setting, but most facilities did not offer a choice of models to address clients' diverse preferences. A minority offered fast-track refills, although this model was often mentioned as desirable. Confidentiality, travel expenses and client waiting times are key elements to consider when planning and rolling out differentiated HIV care.
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Affiliation(s)
- Benedikt Christ
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | | | | | - Martina L Reichmuth
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | | | | | - Matthias Egger
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland.,Centre for Infectious Disease Research and Epidemiology, University of Cape Town, Cape Town, South Africa.,Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Alison Wringe
- London School of Hygiene and Tropical Medicine, London, UK
| | - Marie Ballif
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
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Pham MD, Nguyen HV, Anderson D, Crowe S, Luchters S. Viral load monitoring for people living with HIV in the era of test and treat: progress made and challenges ahead - a systematic review. BMC Public Health 2022; 22:1203. [PMID: 35710413 PMCID: PMC9202111 DOI: 10.1186/s12889-022-13504-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 05/24/2022] [Indexed: 11/10/2022] Open
Abstract
Background In 2016, we conducted a systematic review to assess the feasibility of treatment monitoring for people living with HIV (PLHIV) receiving antiretroviral therapy (ART) in low and middle-income countries (LMICs), in line with the 90-90-90 treatment target. By 2020, global estimates suggest the 90-90-90 target, particularly the last 90, remains unattainable in many LMICs. This study aims to review the progress and identify needs for public health interventions to improve viral load monitoring and viral suppression for PLHIV in LMICs. Methods A literature search was conducted using an update of the initial search strategy developed for the 2016 review. Electronic databases (Medline and PubMed) were searched to identify relevant literature published in English between Dec 2015 and August 2021. The primary outcome was initial viral load (VL) monitoring (the proportion of PLHIV on ART and eligible for VL monitoring who received a VL test). Secondary outcomes included follow-up VL monitoring (the proportion of PLHIV who received a follow-up VL after an initial elevated VL test), confirmation of treatment failure (the proportion of PLHIV who had two consecutive elevated VL results) and switching treatment regimen rates (the proportion of PLHIV who switched treatment regimen after confirmation of treatment failure). Results The search strategy identified 1984 non-duplicate records, of which 34 studies were included in the review. Marked variations in initial VL monitoring coverage were reported across study settings/countries (range: 12–93% median: 74% IQR: 46–82%) and study populations (adults (range: 25–96%, median: 67% IQR: 50–84%), children, adolescents/young people (range: 2–94%, median: 72% IQR: 47–85%), and pregnant women (range: 32–82%, median: 57% IQR: 43–71%)). Community-based models reported higher VL monitoring (median: 85%, IQR: 82-88%) compared to decentralised care at primary health facility (median: 64%, IRQ: 48-82%). Suboptimal uptake of follow-up VL monitoring and low regimen switching rates were observed. Conclusions Substantial gaps in VL coverage across study settings and study populations were evident, with limited data availability outside of sub-Saharan Africa. Further research is needed to fill the data gaps. Development and implementation of innovative, community-based interventions are required to improve VL monitoring and address the “failure cascade” in PLHIV on ART who fail to achieve viral suppression.
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Affiliation(s)
- Minh D Pham
- Burnet Institute, Melbourne, Australia. .,Department of Epidemiology and Preventive Medicine, Faculty of Medicine Nursing and Health Science, Monash University, Melbourne, Australia.
| | - Huy V Nguyen
- Health Innovation and Transformation Centre, Federation University, Victoria, Australia.,School of Medicine and Dentistry, Griffith University, Brisbane, Australia
| | - David Anderson
- Burnet Institute, Melbourne, Australia.,Department of Microbiology, Faculty of Medicine Nursing and Health Science, Monash University, Melbourne, Australia
| | - Suzanne Crowe
- Burnet Institute, Melbourne, Australia.,Central Clinical School, Faculty of Medicine Nursing and Health Science, Monash University, Melbourne, Australia
| | - Stanley Luchters
- Department of Epidemiology and Preventive Medicine, Faculty of Medicine Nursing and Health Science, Monash University, Melbourne, Australia.,Centre for Sexual Health and HIV & AIDS Research, Harare, Zimbabwe.,Department of Public health and Primary care, Ghent University, Ghent, Belgium
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Patel P, Sato K, Bhandari N, Kanagasabai U, Schelar E, Cooney C, Eakle R, Klucking S, Toiv N, Saul J. From policy to practice: uptake of pre-exposure prophylaxis among adolescent girls and young women in United States President's Emergency Plan for AIDS Relief-supported countries, 2017-2020. AIDS 2022; 36:S15-S26. [PMID: 35766572 DOI: 10.1097/qad.0000000000003103] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The US President's Emergency Plan for AIDS Relief's (PEPFAR) first implemented pre-exposure prophylaxis (PrEP) for HIV prevention through the Determined, Resilient, Empowered, AIDS-Free, Mentored and Safe (DREAMS) partnership in 2016. PrEP is a critical intervention to achieve the main objective of DREAMS, reducing new HIV infections among 15-14 year old adolescent girls and young women (AGYW) in 15 high HIV burdened countries. METHODS We describe uptake of PrEP among AGYW in PEPFAR. Most PrEP programs screened persons who tested HIV-negative for eligibility and offered PrEP as part of combination prevention with follow-up, including repeat HIV testing and counseling, at 3-month intervals. Platforms providing comprehensive services for AGYW were also leveraged. We examined two PEPFAR monitoring indicators, using the FY20Q4 Monitoring, Evaluation, Reporting (MER) indicator dataset to assess progress in PrEP uptake, and descriptive narratives to understand successes and challenges from fiscal year 2017 to 2020. To assess coverage, we calculated the PrEP to Need ratio (PnR) using a published methodology. RESULTS From FY2017 to FY2020, 576570 total clients initiated PrEP and the number of PEPFAR countries offering PrEP doubled from 12 to 24. Of 360073 (62% of total) initiations among women, 52% were among AGYW with steady increases from year to year. Among all AGYW, 20-24-year-old women represented a significantly higher proportion of PrEP initiators than adolescents (15-19years) (64 versus 36%, P < 0.05). Of all 186985 PrEP initiations among AGYW, 99% were in DREAMS countries. Barriers, such as low demand and adherence, were addressed through outreach efforts, including mobile sites, use of technology to educate and support AGYW, media campaigns, and engaging peers in program implementation. We saw a 2.5-fold increase in PrEP uptake among AGYW from 2018 to 2019; by 2020, all DREAMS countries were implementing PrEP. However, PrEP coverage among AGYW in DREAMS countries remains low (PnR range: 0-4.1); only two have a PnR greater than 1 where there were more PrEP users than new HIV diagnoses. CONCLUSION PrEP uptake among AGYW has grown since 2016; however, challenges remain. Tools to improve adherence are needed to improve PrEP persistence among AGYW. National policies to facilitate greater PrEP uptake among adolescents would be beneficial. A greater need for PrEP in DREAMS countries is evident and if realized, will contribute to epidemic control.
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Affiliation(s)
- Pragna Patel
- Division of Global HIV and TB, Centers for Disease Control and Prevention, Atlanta, GA
| | - Kimi Sato
- Office of Global Health and HIV, Peace Corps
| | - Neeta Bhandari
- Office of the Global AIDS Coordinator and Health Diplomacy, Department of State
| | | | - Erin Schelar
- United States Agency for International Development, Washington, DC, USA
| | - Caroline Cooney
- Office of the Global AIDS Coordinator and Health Diplomacy, Department of State
| | - Robyn Eakle
- United States Agency for International Development, Washington, DC, USA
| | - Sara Klucking
- Office of the Global AIDS Coordinator and Health Diplomacy, Department of State
| | - Nora Toiv
- Office of the Global AIDS Coordinator and Health Diplomacy, Department of State
| | - Janet Saul
- Office of the Global AIDS Coordinator and Health Diplomacy, Department of State
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Okere NE, Meta J, Maokola W, Martelli G, van Praag E, Naniche D, Gomez GB, Pozniak A, Rinke de Wit T, de Klerk J, Hermans S. Quality of care in a differentiated HIV service delivery intervention in Tanzania: A mixed-methods study. PLoS One 2022; 17:e0265307. [PMID: 35290989 PMCID: PMC8923447 DOI: 10.1371/journal.pone.0265307] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 02/28/2022] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Differentiated service delivery (DSD) offers benefits to people living with HIV (improved access, peer support), and the health system (clinic decongestion, efficient service delivery). ART clubs, 15-30 clients who usually meet within the community, are one of the most common DSD options. However, evidence about the quality of care (QoC) delivered in ART clubs is still limited. MATERIALS AND METHODS We conducted a concurrent triangulation mixed-methods study as part of the Test & Treat project in northwest Tanzania. We surveyed QoC among stable clients and health care workers (HCW) comparing between clinics and clubs. Using a Donabedian framework we structured the analysis into three levels of assessment: structure (staff, equipment, supplies, venue), processes (time-spent, screenings, information, HCW-attitude), and outcomes (viral load, CD4 count, retention, self-worth). RESULTS We surveyed 629 clients (40% in club) and conducted eight focus group discussions, while 24 HCW (25% in club) were surveyed and 22 individual interviews were conducted. Quantitative results revealed that in terms of structure, clubs fared better than clinics except for perceived adequacy of service delivery venue (94.4% vs 50.0%, p = 0.013). For processes, time spent receiving care was significantly more in clinics than clubs (119.9 vs 49.9 minutes). Regarding outcomes, retention was higher in the clubs (97.6% vs 100%), while the proportion of clients with recent viral load <50 copies/ml was higher in clinics (100% vs 94.4%). Qualitative results indicated that quality care was perceived similarly among clients in clinics and clubs but for different reasons. Clinics were generally perceived as places with expertise and clubs as efficient places with peer support and empathy. In describing QoC, HCW emphasized structure-related attributes while clients focused on processes. Outcomes-related themes such as improved client health status, self-worth, and confidentiality were similarly perceived across clients and HCW. CONCLUSION We found better structure and process of care in clubs than clinics with comparable outcomes. While QoC was perceived similarly in clinics and clubs, its meaning was understood differently between clients. DSD catered to the individual needs of clients, either technical care in the clinic or proximate and social care in the club. Our findings highlight that both clinic and DSD care are required as many elements of QoC were individually perceived.
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Affiliation(s)
- Nwanneka Ebelechukwu Okere
- Amsterdam Institute for Global Health and Development (AIGHD), Department of Global Health, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
- * E-mail:
| | - Judith Meta
- Amsterdam Institute for Global Health and Development (AIGHD), Department of Global Health, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Werner Maokola
- Department of Strategic Information, National AIDS Control Programme, Dodoma, Tanzania
| | | | - Eric van Praag
- Amsterdam Institute for Global Health and Development (AIGHD), Department of Global Health, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Denise Naniche
- ISGlobal -Barcelona Institute for Global Health, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Gabriela B. Gomez
- Department of Global Health and Development London School of Health and Tropical Medicine London, London, United Kingdom
| | - Anton Pozniak
- Chelsea and Westminster Hospital NHS Foundation Trust, and LSHTM London, London, United Kingdom
| | - Tobias Rinke de Wit
- Amsterdam Institute for Global Health and Development (AIGHD), Department of Global Health, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Josien de Klerk
- Amsterdam Institute for Global Health and Development (AIGHD), Department of Global Health, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Sabine Hermans
- Amsterdam Institute for Global Health and Development (AIGHD), Department of Global Health, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
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11
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The Effect of PrEP Use Disclosure on Adherence in a Cohort of Adolescent Girls and Young Women in South Africa. AIDS Behav 2022; 26:1007-1016. [PMID: 34478015 DOI: 10.1007/s10461-021-03455-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/27/2021] [Indexed: 10/20/2022]
Abstract
Effective strategies to support PrEP adherence among adolescent girls and young women (AGYW) are needed. We examined PrEP use disclosure and its effect on adherence among 200 AGYW ages 16-25 initiating PrEP in South Africa to help inform these strategies. We estimated the relative prevalence of high adherence (intracellular tenofovir-diphosphate concentration ≥ 700 fmol/punch) 3- and 6-months after PrEP initiation among those who disclosed vs. did not disclose their PrEP use, both overall and by age. Most AGYW disclosed to a parent (58%), partner (58%), or friend (81%) by month 6. We did not observe a strong effect of disclosure on adherence overall; however, among younger AGYW (≤ 18 years), those who disclosed to a parent were 6.8 times as likely to have high adherence at month 6 than those who did not (95% CI 1.02, 45.56). More work is needed to understand parents' roles as allies and identify ways peers and partners can motivate PrEP use for AGYW.
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12
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Atuhaire L, Shumba CS, Nyasulu PS. "My condition is my secret": perspectives of HIV positive female sex workers on differentiated service delivery models in Kampala Uganda. BMC Health Serv Res 2022; 22:146. [PMID: 35120508 PMCID: PMC8814564 DOI: 10.1186/s12913-022-07561-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 01/28/2022] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Differentiated service delivery (DSD) models for female sex workers (FSWs) continue to be scaled up with the goal of expanding access to HIV services and treatment continuity. However, little is known about FSWs' perspectives on their preferences, facilitators, and barriers to the effective utilization of various DSD models. METHODS We conducted 24 in-depth interviews among FSWs on antiretroviral therapy for at least one year in two drop-in centres and two public health facilities in Kampala, Uganda in January 2021. RESULTS The facility-based individual management model was most preferred, due to a wide array of comprehensive health services, privacy, and professional health workers. Community DSD models were physically accessible, but least preferred due to stigmatization and discrimination, lack of privacy and confidentiality, and limited health services offered. CONCLUSION Targeted strategies to reduce stigma and discrimination and the provision of high-quality services have potential to optimise FSWs' access to HIV services.
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Affiliation(s)
- Lydia Atuhaire
- Division of Epidemiology and Biostatistics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.
| | - Constance S Shumba
- School of Nursing and Midwifery, Aga Khan University, Nairobi, Kenya.,Department of Population Health, Aga Khan University, Nairobi, Kenya
| | - Peter S Nyasulu
- Division of Epidemiology and Biostatistics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.,School of Public Health, Faculty of Medicine and Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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13
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Bassett IV, Yan J, Govere S, Khumalo A, Ngobese N, Shazi Z, Nzuza M, Bunda BA, Wara NJ, Stuckwisch A, Zionts D, Dube N, Tshabalala S, Bogart LM, Parker RA. Uptake of community‐ versus clinic‐based antiretroviral therapy dispensing in the Central Chronic Medication Dispensing and Distribution program in South Africa. J Int AIDS Soc 2022; 25:e25877. [PMID: 35077611 PMCID: PMC8789242 DOI: 10.1002/jia2.25877] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 12/28/2021] [Indexed: 12/30/2022] Open
Abstract
Introduction South Africa's government‐led Central Chronic Medication Dispensing and Distribution (CCMDD) program offers people living with HIV the option to collect antiretroviral therapy at their choice of community‐ or clinic‐based pick‐up points intended to increase convenience and decongest clinics. To understand CCMDD pick‐up point use among people living with HIV, we evaluated factors associated with uptake of a community‐ versus clinic‐based pick‐up point at CCMDD enrolment. Methods We collected baseline data from October 2018 to March 2020 on adults (≥18 years) who met CCMDD clinical eligibility criteria (non‐pregnant, on antiretroviral therapy for ≥1 year and virologically suppressed) as part of an observational cohort in seven public clinics in KwaZulu‐Natal. We identified factors associated with community‐based pick‐up point uptake and fit a multivariable logistic regression model, including age, gender, employment status, self‐perceived barriers to care, self‐efficacy, HIV‐related discrimination, and perceived benefits and challenges of CCMDD. Results and Discussion Among 1521 participants, 67% were females, with median age 36 years (IQR 30–44). Uptake of a community‐based pick‐up point was associated with younger age (aOR 1.18 per 10‐year decrease, 95% CI 1.05–1.33), being employed ≥40 hours per week (aOR 1.42, 95% CI 1.10–1.83) versus being unemployed, no self‐perceived barriers to care (aOR 1.42, 95% CI 1.09–1.86) and scoring between 36 and 39 (aOR 1.44, 95% CI 1.03–2.01) or 40 (aOR 1.91, 95% CI 1.39–2.63) versus 10–35 on the self‐efficacy scale, where higher scores indicate greater self‐efficacy. Additional factors included more convenient pick‐up point location (aOR 2.32, 95% CI 1.77–3.04) or hours (aOR 5.09, 95% CI 3.71–6.98) as perceived benefits of CCMDD, and lack of in‐clinic follow‐up after a missed collection date as a perceived challenge of CCMDD (aOR 4.37, 95% CI 2.30–8.31). Conclusions Uptake of community‐based pick‐up was associated with younger age, full‐time employment, and systemic and structural factors of living with HIV (no self‐perceived barriers to care and high self‐efficacy), as well as perceptions of CCMDD (convenient pick‐up point location and hours, lack of in‐clinic follow‐up). Strategies to facilitate community‐based pick‐up point uptake should be tailored to patients’ age, employment, self‐perceived barriers to care and self‐efficacy to maximize the impact of CCMDD in decongesting clinics.
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Affiliation(s)
- Ingrid V. Bassett
- Massachusetts General Hospital Division of Infectious Diseases Boston Massachusetts USA
- Massachusetts General Hospital Medical Practice Evaluation Center Boston Massachusetts USA
- Center for AIDS Research (CFAR) Harvard University Boston Massachusetts USA
- Harvard Medical School Boston Massachusetts USA
| | - Joyce Yan
- Massachusetts General Hospital Biostatistics Center Boston Massachusetts USA
| | | | | | | | | | | | - Bridget A. Bunda
- Massachusetts General Hospital Medical Practice Evaluation Center Boston Massachusetts USA
| | - Nafisa J. Wara
- Massachusetts General Hospital Medical Practice Evaluation Center Boston Massachusetts USA
| | - Ashley Stuckwisch
- Massachusetts General Hospital Medical Practice Evaluation Center Boston Massachusetts USA
| | - Dani Zionts
- Massachusetts General Hospital Medical Practice Evaluation Center Boston Massachusetts USA
| | | | - Sandile Tshabalala
- South Africa Department of Health Province of KwaZulu‐Natal South Africa
| | | | - Robert A. Parker
- Center for AIDS Research (CFAR) Harvard University Boston Massachusetts USA
- Harvard Medical School Boston Massachusetts USA
- Massachusetts General Hospital Biostatistics Center Boston Massachusetts USA
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14
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Nyakato P, Schomaker M, Fatti G, Tanser F, Euvrard J, Sipambo N, Fox MP, Haas AD, Yiannoutsos CT, Davies MA, Cornell M. Virologic non-suppression and early loss to follow up among pregnant and non-pregnant adolescents aged 15-19 years initiating antiretroviral therapy in South Africa: a retrospective cohort study. J Int AIDS Soc 2022; 25:e25870. [PMID: 35032096 PMCID: PMC8760609 DOI: 10.1002/jia2.25870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 12/20/2021] [Indexed: 11/24/2022] Open
Abstract
Introduction Older adolescents aged 15–19 years continue to have high rates of loss to follow up (LTFU), and high rates of virologic non‐suppression (VNS) compared to younger adolescents and adults. Adolescent females are at risk of pregnancy, which puts those living with HIV at a dual vulnerability. Our study assessed the factors associated with VNS and LTFU in older adolescents (including pregnant females) who initiated antiretroviral therapy (ART) in South Africa. Methods We included adolescents aged 15–19 years initiating ART between 2004 and 2019, with ≥ one viral load (VL) measurement between 4 and 24.5 months, and ≥ 6 months follow‐up, from six South African cohorts of the International epidemiology Databases to Evaluate AIDS‐Southern Africa (IeDEA‐SA). We defined VNS as VL ≥400 copies/ml and LTFU as not being in care for ≥180 days from ART start and not known as transferred out of the clinic or dead in the first 24 months on ART. We examined factors associated with VNS and LTFU using Fine&Gray competing risk models. Results We included a total of 2733 adolescents, 415 (15.2%) males, median (IQR) age at ART start of 18.6 (17.3, 19.4) years. Among females, 585/2318 (25.2%) were pregnant. Over the 24‐month follow‐up, 424 (15.5%) of all adolescents experienced VNS: range (11.1% pregnant females and 20.5% males). Over half of all adolescents were LTFU before any other event could occur. The hazard of VNS reduced with increasing age and CD4 count above 200 cells/μl at ART initiation among all adolescents having adjusted for all measured patient characteristics [adjusted sub‐distribution hazard ratio (aSHR) 19 vs. 15 years: 0.50 (95% CI: 0.36, 0.68), aSHR: >500 vs. ≤200 cells/μl: 0.22 (95% CI: 0.16, 0.31)]. The effect of CD4 count persisted in pregnant females. Increasing age and CD4 count >200 cells/μl were risk factors for LTFU among all adolescents. Conclusions Older adolescents had a high risk of LTFU shortly after ART start and a low risk of VNS, especially those initiating treatment during pregnancy. Interventions addressing adherence and retention should be incorporated into adolescent‐friendly services to prevent VNS and LTFU and endeavour to trace lost adolescents as soon as they are identified.
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Affiliation(s)
- Patience Nyakato
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Michael Schomaker
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.,Institute of Public Health, Medical Decision Making and Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics and Technology, Tyrol, Austria
| | - Geoffrey Fatti
- Kheth'Impilo AIDS-Free Living, Cape Town, South Africa.,Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Frank Tanser
- Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Somkhele, South Africa
| | - Jonathan Euvrard
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.,Khayelitsha ART Programme and Medecins Sans Frontieres, Cape Town, South Africa
| | - Nosisa Sipambo
- Harriet Shezi Children's Clinic, Chris Hani Baragwanath Academic Hospital, Soweto, South Africa
| | - Matthew P Fox
- Department of Epidemiology, Boston University School of Public Health, Boston University, Boston, Massachusetts, USA.,Health Economics & Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Andreas D Haas
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Constantin T Yiannoutsos
- Department of Biostatistics, R.M. Fairbanks School of Public Health, Indiana University, Indianapolis, Indiana, USA
| | - Mary-Ann Davies
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Morna Cornell
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
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15
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Cassidy T, Cornell M, Runeyi P, Dutyulwa T, Kilani C, Duran LT, Zokufa N, de Azevedo V, Boulle A, Horsburgh CR, Fox MP. Attrition from HIV care among youth initiating ART in youth-only clinics compared with general primary healthcare clinics in Khayelitsha, South Africa: a matched propensity score analysis. J Int AIDS Soc 2022; 25:e25854. [PMID: 35077610 PMCID: PMC8789247 DOI: 10.1002/jia2.25854] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 11/25/2021] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Youth living with HIV (YLWH) are less likely to initiate antiretroviral therapy (ART) and remain in care than older adults. It is important to identify effective strategies to address the needs of this growing population and prevent attrition from HIV care. Since 2008, two clinics have offered youth-targeted services exclusively to youth aged 12-25 in Khayelitsha, a high HIV-prevalence, low-income area in South Africa. We compared ART attrition among youth in these two clinics to youth in regular clinics in the same area. METHODS We conducted a propensity score matched cohort study of individuals aged 12-25 years initiating ART at eight primary care clinics in Khayelitsha between 1 January 2008 and 1 April 2018. We compared attrition, defined as death or loss to follow-up, between those attending two youth clinics and those attending general primary healthcare clinics, using Cox proportional hazards regression. Follow-up time began at ART initiation and ended at attrition, clinic transfer or dataset closure. We conducted sub-analyses of patients attending adherence clubs. RESULTS The distribution of age, sex and CD4 count at ART initiation was similar across Youth Clinic A (N = 1383), Youth Clinic B (N = 1299) and general clinics (N = 3056). Youth at youth clinics were more likely than those at general clinics to have initiated ART before August 2011 (Youth Clinic A: 16%, Youth Clinic B: 23% and general clinics: 11%). Youth clinics were protective against attrition: HR 0.81 (95% CI: 0.71-0.92) for Youth Clinic A and 0.85 (0.74-0.98) for Youth Clinic B, compared to general clinics. Youth Clinic A club patients had lower attrition after joining an adherence club than general clinic patients in adherence clubs (crude HR: 0.56, 95% CI: 0.32-0.96; adjusted HR: 0.48, 95% CI: 0.28-0.85), while Youth Clinic B showed no effect (crude HR: 0.83, 95% CI: 0.48-1.45; adjusted HR: 1.07, 95% CI: 0.60-1.90). CONCLUSIONS YLWH were more likely to be retained in ART care in two different youth-targeted clinics compared to general clinics in the same area. Our findings suggest that multiple approaches to making clinics more youth-friendly can contribute to improving retention in this important group.
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Affiliation(s)
- Tali Cassidy
- Médecins Sans Frontières, Cape Town, South Africa
- Division of Public Health Medicine, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Morna Cornell
- Centre for Infectious Disease Epidemiology & Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | | | | | | | | | | | | | - Andrew Boulle
- Centre for Infectious Disease Epidemiology & Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
- Western Cape Provincial Department of Health, Western Cape, South Africa
| | - C Robert Horsburgh
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, USA
- Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Matthew P Fox
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, USA
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
- Health Economics and Epidemiology Research Office, Faculty of Health Sciences, Department of Internal Medicine, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
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16
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Mando RO, Moghadassi M, Juma E, Ogollah C, Packel L, Kulzer JL, Kadima J, Odhiambo F, Eshun-Wilson I, Kim HY, Cohen CR, Bukusi EA, Geng E. Patient preferences for HIV service delivery models; a Discrete Choice Experiment in Kisumu, Kenya. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000614. [PMID: 36962597 PMCID: PMC10021384 DOI: 10.1371/journal.pgph.0000614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 09/26/2022] [Indexed: 11/07/2022]
Abstract
Novel "differentiated service delivery" models for HIV treatment that reduce clinic visit frequency, minimize waiting time, and deliver treatment in the community promise retention improvement for HIV treatment in Sub-Saharan Africa. Quantitative assessments of differentiated service delivery (DSD) feature most preferred by patient populations do not widely exist but could inform selection and prioritization of different DSD models. We used a discrete choice experiment (DCE) to elicit patient preferences of HIV treatment services and how they differ across DSD models. We surveyed 18+year-olds, enrolled in HIV care for ≥6 months between February-March, 2019 at four facilities in Kisumu County, Kenya. DCE offered patients a series of comparisons between three treatment models, each varying across seven attributes: ART refill location, quantity of dispensed ART at each refill, medication pick-up hours, type of adherence support, clinical visit frequency, staff attitude, and professional cadre of person providing ART refills. We used hierarchical Bayesian model to estimate attribute importance and relative desirability of care characteristics, latent class analysis (LCA) for groups of preferences and mixed logit model for willingness to trade analysis. Of 242 patients, 128 (53.8%) were females and 150 (62.8%) lived in rural areas. Patients placed greatest importance on ART refill location [19.5% (95% CI 18.4, 10.6) and adherence support [19.5% (95% CI 18.17, 20.3)], followed by staff attitude [16.1% (95% CI 15.1, 17.2)]. In the mixed logit, patients preferred nice attitude of staff (coefficient = 1.60), refill ART health center (Coeff = 1.58) and individual adherence support (Coeff = 1.54), 3 or 6 months for ART refill (Coeff = 0.95 and 0.80, respectively) and pharmacists (instead of lay health workers) providing ART refill (Coeff = 0.64). No differences were observed by gender or urbanicity. LCA revealed two distinct groups (59.5% vs. 40.5%). Participants preferred 3 to 6-month refill interval or clinic visit spacing, which DSD offers stable patients. While DSD has encouraged community ART group options, our results suggest strong preferences for ART refills from health-centers or pharmacists over lay-caregivers or community members. These preferences held across gender&urban/rural subpopulations.
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Affiliation(s)
- Raphael Onyango Mando
- Research Care and Training Program, Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Michelle Moghadassi
- Department of Gynecology, Obstetrics, and Reproductive Sciences, University of California San Francisco, California, United States of America
| | - Eric Juma
- Research Care and Training Program, Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Cirilus Ogollah
- Research Care and Training Program, Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Laura Packel
- The University of California Berkeley, Berkeley, California, United States of America
| | - Jayne Lewis Kulzer
- Department of Gynecology, Obstetrics, and Reproductive Sciences, University of California San Francisco, California, United States of America
- The University of California Berkeley, Berkeley, California, United States of America
| | - Julie Kadima
- Research Care and Training Program, Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Francesca Odhiambo
- Research Care and Training Program, Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Ingrid Eshun-Wilson
- Division of Infectious Diseases, Department of Internal Medicine, Washington University in St. Louis, St. Louis, Missouri, United States of America
| | - Hae-Young Kim
- School of Medicine, New York University, New York, New York, United States of America
| | - Craig R Cohen
- Department of Gynecology, Obstetrics, and Reproductive Sciences, University of California San Francisco, California, United States of America
| | - Elizabeth A Bukusi
- Research Care and Training Program, Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
- Department of Gynecology, Obstetrics, and Reproductive Sciences, University of California San Francisco, California, United States of America
- The University of California Berkeley, Berkeley, California, United States of America
| | - Elvin Geng
- Division of Infectious Diseases, Department of Internal Medicine, Washington University in St. Louis, St. Louis, Missouri, United States of America
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17
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Mukumbang FC, Ndlovu S, van Wyk B. Comparing Patients' Experiences in Three Differentiated Service Delivery Models for HIV Treatment in South Africa. QUALITATIVE HEALTH RESEARCH 2022; 32:238-254. [PMID: 34911400 PMCID: PMC8727825 DOI: 10.1177/10497323211050371] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
Differentiated service delivery for HIV treatment seeks to enhance medication adherence while respecting the preferences of people living with HIV. Nevertheless, patients' experiences of using these differentiated service delivery models or approaches have not been qualitatively compared. Underpinned by the tenets of descriptive phenomenology, we explored and compared the experiences of patients in three differentiated service delivery models using the National Health Services' Patient Experience Framework. Data were collected from 68 purposively selected people living with HIV receiving care in facility adherence clubs, community adherence clubs, and quick pharmacy pick-up. Using the constant comparative thematic analysis approach, we compared themes identified across the different participant groups. Compared to facility adherence clubs and community adherence clubs, patients in the quick pharmacy pick-up model experienced less information sharing; communication and education; and emotional/psychological support. Patients' positive experience with a differentiated service delivery model is based on how well the model fits into their HIV disease self-management goals.
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Affiliation(s)
- Ferdinand C. Mukumbang
- University of the Western Cape, Cape Town, South Africa
- School of Medicine, University of Washington, Seattle, WA, USA
| | | | - Brian van Wyk
- University of the Western Cape, Cape Town, South Africa
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18
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Orth Z, van Wyk B. A Facility-based Family Support Intervention to Improve Treatment Outcomes for Adolescents on Antiretroviral Therapy in the Cape Metropole, South Africa. J Int Assoc Provid AIDS Care 2021; 20:23259582211059289. [PMID: 34821168 PMCID: PMC8641108 DOI: 10.1177/23259582211059289] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Adolescents living with human immunodeficiency virus (HIV) (ALHIV) globally, report worse treatment outcomes compared to adults and children on antiretroviral therapy (ART). We conducted a photovoice study with eighteen ALHIV to explore experiences and challenges of being on ART, and individual interviews with 5 health workers to describe the challenges in treating ALHIV. The facility implemented the Family club intervention to facilitate caregivers (parent/guardians) supporting ALHIV on treatment. The health workers revealed that "disclosing HIV status" to children was the biggest challenge for caregivers and health workers. Participating ALHIV reported that family support and having a positive mentality were instrumental for continued treatment adherence. However, disclosure of HIV status to friends remained a challenge due to pervasive community stigma. Treatment fatigue and side-effects were also barriers to adherence. Family support was instrumental in facilitating adherence support for ALHIV. However, this (intervention) should include peer support to improve positive mental well-being in ALHIV.
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Affiliation(s)
- Zaida Orth
- School of Public Health, 56390University of the Western Cape, Bellville, South Africa
| | - Brian van Wyk
- School of Public Health, 56390University of the Western Cape, Bellville, South Africa
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19
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Garcia M, Luecke E, Mayo AJ, Scheckter R, Ndase P, Kiweewa FM, Kemigisha D, Musara P, Mansoor LE, Singh N, Woeber K, Morar NS, Jeenarain N, Gaffoor Z, Gondwe DK, Makala Y, Fleurs L, Reddy K, Palanee-Phillips T, Baeten JM, van der Straten A, Soto-Torres L, Torjesen K. Impact and experience of participant engagement activities in supporting dapivirine ring use among participants enrolled in the phase III MTN-020/ASPIRE study. BMC Public Health 2021; 21:2041. [PMID: 34749675 PMCID: PMC8576984 DOI: 10.1186/s12889-021-11919-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 09/24/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Low adherence to investigational products can negatively impact study outcomes, limiting the ability to demonstrate efficacy. To continue advancing potential new HIV prevention technologies, efforts are needed to improve adherence among study participants. In MTN-020/ASPIRE, a phase III randomized, double-blind, placebo-controlled study of the dapivirine vaginal ring carried out across 15 sites in sub-Saharan Africa, a multifaceted approach to adherence support was implemented, including a strong focus on participant engagement activities (PEAs). In this manuscript, we describe PEAs and participant attendance, and analyze the potential impact of PEAs on ring use. METHODS All sites implemented PEAs and submitted activity and attendance reports to the study management team throughout the study. Participant demographics were collected via case report forms. Residual dapivirine remaining in the last ring returned by each participant was used to estimate drug released from the ring, which was then adjusted for time participants had the ring to calculate probable use categorized into three levels (low/intermittent/high). Product use was connected to PEA attendance using participant identification numbers. We used multivariate Poisson regression with robust standard errors to explore differences in ring use between PEA attendance groups and reviewed qualitative reports for illustrative quotes highlighting participant experiences with PEAs. RESULTS 2312 of 2629 study participants attended at least one of 389 PEAs conducted across sites. Participant country and partner knowledge of study participation were most strongly associated with PEA attendance (p < 0.005) with age, education, and income status also associated with event attendance (p < 0.05). When controlling for these variables, participants who attended at least one event were more likely to return a last ring showing at least some use (RR = 1.40) than those who never attended an event. There was a stronger correlation between a last returned ring showing use and participant attendance at multiple events (RR = 1.52). CONCLUSIONS Our analysis supports the growing body of work illustrating the importance of meaningfully engaging research participants to achieve study success and aligns with other analyses of adherence support efforts during ASPIRE. While causation between PEA attendance and product use cannot be established, residual drug levels in returned rings strongly correlated with participant attendance at PEAs, and the benefits of incorporating PEAs should be considered when designing future studies of investigational products.
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Affiliation(s)
- Morgan Garcia
- Global Health Population and Nutrition, FHI, Durham, NC, 360, USA.
| | - Ellen Luecke
- Women's Global Health Imperative (WGHI) RTI International, Berkeley, CA, USA; ASTRA Consulting, Kensington, CA, USA
| | - Ashley J Mayo
- Global Health Population and Nutrition, FHI, Durham, NC, 360, USA
| | - Rachel Scheckter
- Global Health Population and Nutrition, FHI, Durham, NC, 360, USA
| | - Patrick Ndase
- Population Services International (PSI), 1120 19th St. NW, Washington, DC, USA
| | - Flavia Matovu Kiweewa
- Makerere University-Johns Hopkins University (MU-JHU) Research Collaboration, Kampala, Uganda
| | - Doreen Kemigisha
- Makerere University-Johns Hopkins University (MU-JHU) Research Collaboration, Kampala, Uganda
| | - Petina Musara
- University of Zimbabwe College of Health Sciences-Clinical Trials Research Centre, Harare, Zimbabwe
| | - Leila E Mansoor
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa
| | - Nishanta Singh
- HIV Prevention Research Unit (HPRU), South African Medical Research Council (SAMRC), Durban, South Africa
| | - Kubashni Woeber
- HIV Prevention Research Unit (HPRU), South African Medical Research Council (SAMRC), Durban, South Africa
| | - Neetha S Morar
- HIV Prevention Research Unit (HPRU), South African Medical Research Council (SAMRC), Durban, South Africa
| | - Nitesha Jeenarain
- HIV Prevention Research Unit (HPRU), South African Medical Research Council (SAMRC), Durban, South Africa
| | - Zakir Gaffoor
- HIV Prevention Research Unit (HPRU), South African Medical Research Council (SAMRC), Durban, South Africa
| | - Daniel K Gondwe
- College of Medicine - Johns Hopkins Bloomberg School of Public Health, Blantyre, Malawi
| | - Yvonne Makala
- University of North Carolina Project, Lilongwe, Malawi
| | - Llewellyn Fleurs
- Desmond Tutu HIV Foundation, Emavundleni Clinical Research Site, Cape Town, South Africa
| | - Krishnaveni Reddy
- Wits Reproductive Health and HIV Institute (Wits RHI), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Thesla Palanee-Phillips
- Wits Reproductive Health and HIV Institute (Wits RHI), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Jared M Baeten
- Departments of Global Health, Medicine, and Epidemiology, University of Washington, Seattle, WA, USA
| | - Ariane van der Straten
- Women's Global Health Imperative (WGHI) RTI International, Berkeley, CA, USA; ASTRA Consulting, Kensington, CA, USA.,Center for AIDS Prevention Studies (CAPS), University of California San Francisco, San Francisco, CA, USA
| | - Lydia Soto-Torres
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
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20
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Kintu TM, Ssewanyana AM, Kyagambiddwa T, Nampijja PM, Apio PK, Kitaka J, Kabakyenga JK. Exploring drivers and barriers to the utilization of community client-led ART delivery model in South-Western Uganda: patients' and health workers' experiences. BMC Health Serv Res 2021; 21:1129. [PMID: 34670564 PMCID: PMC8527820 DOI: 10.1186/s12913-021-07105-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 09/28/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND In an effort to accommodate the growing number of HIV clients, improve retention in care and reduce health care burden, the differentiated service delivery (DSD) models were introduced in 2014. One such model, Community Client-Led ART Delivery (CCLAD) was rolled out in Uganda in 2017. The extent of utilization of this model has not been fully studied. The aim of the study was to explore the patients' and health workers' experiences on the utilization of CCLAD model at Bwizibwera Health Centre IV, south western Uganda. METHODS This was a descriptive study employing qualitative methods. The study had 68 purposively selected participants who participated in 10 focus group discussions with HIV clients enrolled in CCLAD; 10 in-depth interviews with HIV clients not enrolled in CCLAD and 6 in-depth interviews with the health workers. Key informant interviews were held with the 2 focal persons for DSD. The discussions and interviews were audio recorded, transcribed verbatim and then translated. Both deductive and inductive approaches were employed to analyse the data using in NVivo software. RESULTS Patients' and health workers' experiences in this study were categorized as drivers and barriers to the utilization of the CCLAD model. The main drivers for utilization of this model at different levels were: individual (reduced costs, living positively with HIV, improved patient self-management), community (peer support and contextual factors) and health system (reduced patient congestion at the health centre, caring health workers as well as CCLAD sensitization by health workers). However, significant barriers to the utilization of this community-based model were: individual (personal values and preferences, lack of commitment of CCLAD group members), community (stigma, gender bias) and health system (frequent drug stockouts, certain implementation challenges, fluctuating implementing partner priorities, shortage of trained health workers and insufficient health education by health workers). CONCLUSION Based on our findings the CCLAD model is meeting the objectives set out by Differentiated Service Delivery for HIV care and treatment. Notwithstanding the benefits, challenges remain which call on the Ministry of Health and other implementing partners to address these hindrances to facilitate the scalability, sustainability and the realisation of the full-range of benefits that the model presents.
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Affiliation(s)
- Timothy Mwanje Kintu
- Faculty of Medicine, Mbarara University of Science and Technology, P.O. Box 1410, Mbarara, Uganda
| | - Anna Maria Ssewanyana
- Faculty of Medicine, Mbarara University of Science and Technology, P.O. Box 1410, Mbarara, Uganda
| | - Tonny Kyagambiddwa
- Faculty of Medicine, Mbarara University of Science and Technology, P.O. Box 1410, Mbarara, Uganda
| | - Pretty Mariam Nampijja
- Faculty of Medicine, Mbarara University of Science and Technology, P.O. Box 1410, Mbarara, Uganda
| | - Patience Kevin Apio
- Faculty of Medicine, Mbarara University of Science and Technology, P.O. Box 1410, Mbarara, Uganda
| | - Jessica Kitaka
- Faculty of Medicine, Mbarara University of Science and Technology, P.O. Box 1410, Mbarara, Uganda
| | - Jerome Kahuma Kabakyenga
- Faculty of Medicine, Mbarara University of Science and Technology, P.O. Box 1410, Mbarara, Uganda.
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21
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Gausi B, Berkowitz N, Jacob N, Oni T. Treatment outcomes among adults with HIV/non-communicable disease multimorbidity attending integrated care clubs in Cape Town, South Africa. AIDS Res Ther 2021; 18:72. [PMID: 34649586 PMCID: PMC8515722 DOI: 10.1186/s12981-021-00387-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Accepted: 09/15/2021] [Indexed: 12/01/2022] Open
Abstract
Background The growing burden of the HIV and non-communicable disease (NCD) syndemic in Sub- Saharan Africa has necessitated introduction of integrated models of care in order to leverage existing HIV care infrastructure for NCDs. However, there is paucity of literature on treatment outcomes for multimorbid patients attending integrated care. We describe 12-month treatment outcomes among multimorbid patients attending integrated antiretroviral treatment (ART) and NCD clubs in Cape Town, South Africa. Methods As part of an integrated clubs (IC) model pilot implemented in 2016 by the local government at two primary health care clinics in Cape Town, we identified all multimorbid patients who were enrolled for IC for at least 12 months by August 2017. Mean adherence percentages (using proxy of medication collection and attendance of club visits) and optimal disease control (defined as the proportion of participants achieving optimal blood pressure, glycosylated haemoglobin control and HIV viral load suppression where appropriate) were calculated at 12 months before, at the point of IC enrolment and 12 months after IC enrolment. Predictors of NCD control 12 months post IC enrolment were investigated using multivariable logistic regression. Results As of 31 August 2017, 247 HIV-infected patients in total had been enrolled into IC for at least 12 months. Of these, 221 (89.5%) had hypertension, 4 (1.6%) had diabetes mellitus and 22 (8.9%) had both diseases. Adherence was maintained before and after IC enrolment with mean adherence percentages of 92.2% and 94.2% respectively. HIV viral suppression rates were 98.6%, 99.5% and 99.4% at the three time points respectively. Retention in care was high with 6.9% lost to follow up at 12 months post IC enrolment. Across the 3 time-points, optimal blood pressure control was achieved in 43.1%, 58.9% and 49.4% of participants while optimal glycaemic control was achieved in 47.4%, 87.5% and 53.3% of participants with diabetes respectively. Multivariable logistic analyses showed no independent variables significantly associated with NCD control. Conclusion Multimorbid adults living with HIV achieved high levels of HIV control in integrated HIV and NCD clubs. However, intensified interventions are needed to maintain NCD control in the long term. Supplementary Information The online version contains supplementary material available at 10.1186/s12981-021-00387-3.
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22
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Gilbert HN, Wyatt MA, Pisarski EE, Asiimwe S, van Rooyen H, Seeley J, Shahmanesh M, Turyamureeba B, van Heerden A, Adeagbo O, Celum CL, Barnabas RV, Ware NC. How community ART delivery may improve HIV treatment outcomes: Qualitative inquiry into mechanisms of effect in a randomized trial of community-based ART initiation, monitoring and re-supply (DO ART) in South Africa and Uganda. J Int AIDS Soc 2021; 24:e25821. [PMID: 34624173 PMCID: PMC8500674 DOI: 10.1002/jia2.25821] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 08/03/2021] [Indexed: 02/05/2023] Open
Abstract
Introduction UNAIDS fast track targets for ending the AIDS epidemic by 2030 call for viral suppression in 95% of people using antiretroviral therapy (ART) to treat HIV infection. Difficulties in linking to care following a positive HIV test have impeded progress towards meeting treatment targets. Community‐based HIV services may reduce linkage barriers and have been associated with high retention and favourable clinical outcomes. We use qualitative data from The Delivery Optimization of Antiretroviral Therapy (DO ART) Study, a three‐arm randomized trial of community ART initiation, monitoring and re‐supply conducted in western Uganda and KwaZulu‐Natal South Africa, to identify mechanisms through which community ART delivery may improve treatment outcomes, defined as viral suppression in people living with HIV (PLHIV). Methods We conducted open‐ended interviews with a purposeful sample of 150 DO ART participants across study arms and study sites, from October 2016 to November 2019. Interviews covered experiences of: (1) HIV testing; (2) initiating and refilling ART; and (3) participating in the DO ART Study. A combined inductive content analytic and thematic approach was used to characterize mechanisms through which community delivery of ART may have contributed to viral suppression in the DO ART trial. Results The analysis yielded four potential mechanisms drawn from qualitative data representing the perspectives and priorities of DO ART participants. Empowering participants to schedule, re‐schedule and select the locations of community‐based visits via easy phone contact with clinical staff is characterized as flexibility. Integration refers to combining the components of clinic‐based visits into single interaction with a healthcare provider. Providers” willingness to talk at length with participants during visits, addressing non‐HIV as well as HIV‐related concerns, is termed “a slower pace”. Finally, increased efficiency denotes the time savings and increased income‐generating opportunities for participants brought about by delivering services in the community. Conclusions Understanding the mechanisms through which HIV service delivery innovations produce an effect is key to transferability and potential scale‐up. The perspectives and priorities of PLHIV can indicate actionable changes for HIV care programs that may increase engagement in care and improve treatment outcomes.
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Affiliation(s)
- Hannah N Gilbert
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Monique A Wyatt
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA.,Harvard Global, Cambridge, Massachusetts, USA
| | - Emily E Pisarski
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Stephen Asiimwe
- Mbarara University of Science and Technology, Mbarara, Uganda.,Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts, USA.,Integrated Community-based Initiatives, Kabwohe, Uganda
| | - Heidi van Rooyen
- Human Sciences Research Council, KwaZulu-Natal, South Africa.,SAMRC/Wits Developmental Pathways for Health Research Unit, Department of Paediatrics, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Janet Seeley
- London School of Hygiene and Tropical Medicine, London, UK.,Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - Maryam Shahmanesh
- Africa Health Research Institute, KwaZulu-Natal, South Africa.,Institute for Global Health, University College London, London, UK
| | | | - Alastair van Heerden
- Human Sciences Research Council, KwaZulu-Natal, South Africa.,SAMRC/Wits Developmental Pathways for Health Research Unit, Department of Paediatrics, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Connie L Celum
- Departments of Global Health and Medicine, University of Washington, Seattle, Washington, USA
| | - Ruanne V Barnabas
- Departments of Global Health and Medicine, University of Washington, Seattle, Washington, USA
| | - Norma C Ware
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA.,Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
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- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
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23
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Mash R, Christian C, Chigwanda RV. Alternative mechanisms for delivery of medication in South Africa: A scoping review. S Afr Fam Pract (2004) 2021; 63:e1-e8. [PMID: 34476963 PMCID: PMC8424755 DOI: 10.4102/safp.v63i1.5274] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 05/19/2021] [Accepted: 06/22/2021] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND The number of people in South Africa with chronic conditions is a challenge to the health system. In response to the coronavirus infection, health services in Cape Town introduced home delivery of medication by community health workers. In planning for the future, they requested a scoping review of alternative mechanisms for delivery of medication to patients in primary health care in South Africa. METHODS Databases were systematically searched using a comprehensive search strategy to identify studies from the last 10 years. A methodological guideline for conducting scoping reviews was followed. A standardised template was used to extract data and compare study characteristics and findings. Data was analysed both quantitatively and qualitatively. RESULTS A total of 4253 publications were identified and 26 included. Most publications were from the last 5 years (n = 21), research (n = 24), Western Cape (n = 15) and focused on adherence clubs (n = 17), alternative pick-up-points (n = 14), home delivery (n = 5) and HIV (n = 17). The majority of alternative mechanisms were supported by a centralised dispensing and packaging system. New technology such as smart lockers and automated pharmacy dispensing units have been piloted. Patients benefited from these alternatives and had improved adherence. Available evidence suggests alternative mechanisms were cheaper and more beneficial than attending the facility to collect medication. CONCLUSION A mix of options tailored to the local context and patient choice that can be adequately managed by the system would be ideal. More economic evaluations are required of the alternatives, particularly before going to scale and for newer technology.
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Affiliation(s)
- Robert Mash
- Division of Family Medicine and Primary Care, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town.
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24
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Steward WT, Agnew E, de Kadt J, Ratlhagana MJ, Sumitani J, Gilmore HJ, Grignon J, Shade SB, Tumbo J, Barnhart S, Lippman SA. Impact of SMS and peer navigation on retention in HIV care among adults in South Africa: results of a three-arm cluster randomized controlled trial. J Int AIDS Soc 2021; 24:e25774. [PMID: 34435440 PMCID: PMC8387209 DOI: 10.1002/jia2.25774] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 06/10/2021] [Accepted: 07/08/2021] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION Few interventions have demonstrated improved retention in care for people living with HIV (PLHIV) in sub-Saharan Africa. We tested the efficacy of two personal support interventions - one using text messaging (SMS-only) and the second pairing SMS with peer navigation (SMS+PN) - to improve HIV care retention over one year. METHODS In a cluster randomized control trial (NCT# 02417233) in North West Province, South Africa, we randomized 17 government clinics to three conditions: SMS-only (6), SMS+PN (7) or standard of care (SOC; 4). Participants at SMS-only clinics received appointment reminders, biweekly healthy living messages and twice monthly SMS check-ins. Participants at SMS+PN clinics received SMS appointment reminders and healthy living messages and spoke at least twice monthly with peer navigators (PLHIV receiving care) to address barriers to care. Outcomes were collected through biweekly clinical record extraction and surveys at baseline, six and 12 months. Retention in HIV care over one year was defined as clinic visits every three months for participants on antiretroviral therapy (ART) and CD4 screening every six months for pre-ART participants. We used generalized estimating equations, adjusting for clustering by clinic, to test for differences across conditions. RESULTS Between October 2014 and April 2015, we enrolled 752 adult clients recently diagnosed with HIV (SOC: 167; SMS-only: 289; SMS+PN: 296). Individuals in the SMS+PN arm had approximately two more clinic visits over a year than those in other arms (p < 0.01) and were more likely to be retained in care over one year than those in SOC clinics (54% vs. 38%; OR: 1.77, CI: 1.02, 3.10). Differences between SMS+PN and SOC conditions remained significant when restricting analyses to the 628 participants on ART (61% vs. 45% retained; OR: 1.78, CI: 1.08, 2.93). The SMS-only intervention did not improve retention relative to SOC (40% vs. 38%, OR: 1.12, CI: 0.63, 1.98). CONCLUSIONS A combination of SMS appointment reminders with personalized, peer-delivered support proved effective at enhancing retention in HIV care over one year. While some clients may only require appointment reminders, the SMS+PN approach offers increased flexibility and tailored, one-on-one support for patients struggling with more substantive challenges.
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Affiliation(s)
- Wayne T Steward
- Division of Prevention ScienceDepartment of MedicineUniversity of CaliforniaSan FranciscoCAUSA
| | - Emily Agnew
- Division of Prevention ScienceDepartment of MedicineUniversity of CaliforniaSan FranciscoCAUSA
| | - Julia de Kadt
- International Training and Education Center for Health (I‐TECH)PretoriaRepublic of South Africa
| | - Mary Jane Ratlhagana
- International Training and Education Center for Health (I‐TECH)PretoriaRepublic of South Africa
| | - Jeri Sumitani
- International Training and Education Center for Health (I‐TECH)PretoriaRepublic of South Africa
| | - Hailey J Gilmore
- Division of Prevention ScienceDepartment of MedicineUniversity of CaliforniaSan FranciscoCAUSA
| | - Jessica Grignon
- International Training and Education Center for Health (I‐TECH)PretoriaRepublic of South Africa
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
- International Training and Education Center for Health (I‐TECH) South AfricaPretoriaRepublic of South Africa
| | - Starley B Shade
- Division of Prevention ScienceDepartment of MedicineUniversity of CaliforniaSan FranciscoCAUSA
- Institute for Global Health SciencesDepartment of Epidemiology and BiostatisticsUniversity of CaliforniaSan FranciscoCAUSA
| | - John Tumbo
- Department of Family Medicine and Primary Health CareSefako Makgatho Health Sciences UniversityPretoriaRepublic of South Africa
| | - Scott Barnhart
- Department of Global HealthUniversity of WashingtonSeattleWAUSA
- International Training and Education Center for Health (I‐TECH) South AfricaPretoriaRepublic of South Africa
| | - Sheri A Lippman
- Division of Prevention ScienceDepartment of MedicineUniversity of CaliforniaSan FranciscoCAUSA
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25
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Limbada M, Zijlstra G, Macleod D, Ayles H, Fidler S. A systematic review of the effectiveness of non- health facility based care delivery of antiretroviral therapy for people living with HIV in sub-Saharan Africa measured by viral suppression, mortality and retention on ART. BMC Public Health 2021; 21:1110. [PMID: 34112135 PMCID: PMC8194040 DOI: 10.1186/s12889-021-11053-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Accepted: 05/12/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Alternative models for sustainable antiretroviral treatment (ART) delivery are necessary to meet the increasing demand to maintain population-wide ART for all people living with HIV (PLHIV) in sub-Saharan Africa. We undertook a review of published literature comparing health facility-based care (HFBC) with non-health facility based care (nHFBC) models of ART delivery in terms of health outcomes; viral suppression, loss to follow-up, retention and mortality. METHODS We conducted a systematic search of Medline, Embase and Global Health databases from 2010 onwards. UNAIDS reports, WHO guidelines and abstracts from conferences were reviewed. All studies measuring at least one of the following outcomes, viral load suppression, loss-to-follow-up (LTFU) and mortality were included. Data were extracted, and a descriptive analysis was performed. Risk of bias assessment was done for all studies. Pooled estimates of the risk difference (for viral suppression) and hazard ratio (for mortality) were made using random-effects meta-analysis. RESULTS Of 3082 non-duplicate records, 193 were eligible for full text screening of which 21 published papers met the criteria for inclusion. The pooled risk difference of viral load suppression amongst 4 RCTs showed no evidence of a difference in viral suppression (VS) between nHFBC and HFBC with an overall estimated risk difference of 1% [95% CI -1, 4%]. The pooled hazard ratio of mortality amongst 2 RCTs and 4 observational cohort studies showed no evidence of a difference in mortality between nHFBC and HFBC with an overall estimated hazard ratio of 1.01 [95% CI 0.88, 1.16]. Fifteen studies contained data on LTFU and 13 studies on retention. Although no formal quantitative analysis was performed on these outcomes due to the very different definitions between papers, it was observed that the outcomes appeared similar between HFBC and nHFBC. CONCLUSIONS Review of current literature demonstrates comparable outcomes for nHFBC compared to HFBC ART delivery programmes in terms of viral suppression, retention and mortality. PROSPERO NUMBER CRD42018088194 .
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Affiliation(s)
- Mohammed Limbada
- Zambart House, PO Box 50697, UNZA-Ridgeway Campus, Lusaka, Zambia.
| | | | - David Macleod
- MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
| | - Helen Ayles
- Zambart House, PO Box 50697, UNZA-Ridgeway Campus, Lusaka, Zambia
- MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
| | - Sarah Fidler
- Imperial College and Imperial college NIHR BRC, London, UK
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26
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Owachi D, Anguzu G, Kigozi J, Cox J, Castelnuovo B, Semitala F, Meya D. Virologic suppression and associated factors in HIV infected Ugandan female sex workers: a cross-sectional study. Afr Health Sci 2021; 21:603-613. [PMID: 34795713 PMCID: PMC8568220 DOI: 10.4314/ahs.v21i2.15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Key populations have disproportionately higher HIV prevalence rates than the general population. OBJECTIVE To determine the level of virologic suppression and associated factors in female Commercial Sex Workers (CSW) who completed six months of ART and compare with the female general population (GP). METHODS Clinical records of CSW and GPs who initiated ART between December 2014 to December 2016 from seven urban clinics were analyzed to determine virologic suppression (viral load < 1000 copies/ml) and associated factors. RESULTS We identified 218 CSW and 182 female GPs. CSW had median age of 28 (IQR 25-31) vs 31 (IQR 26-37); median baseline CD4 446 (IQR 308-696) vs 352 (IQR 164-493) cells/microL; and optimal ART adherence levels at 70.6% vs 92.8% respectively, compared to GP. Virologic suppression in CSW and GPs was 85.7% and 89.6% respectively, P=0.28. Overall virologic suppression in CSW was 55% while Retention in care after 6 months of ART was 77.5%. Immediate ART initiation (<2weeks) and tuberculosis independently predicted virologic suppression in CSW with adjusted odds ratios 0.07 (95% C.I. 0.01-0.55, P=0.01) and 0.09 (95% C.I. 0.01-0.96, P=0.046) respectively. CONCLUSION Virologic suppression in both groups is similar, however, intensified follow-up is needed to improve treatment outcomes.
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27
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O'Laughlin KN, Greenwald K, Rahman SK, Faustin ZM, Ashaba S, Tsai AC, Ware NC, Kambugu A, Bassett IV. A Social-Ecological Framework to Understand Barriers to HIV Clinic Attendance in Nakivale Refugee Settlement in Uganda: a Qualitative Study. AIDS Behav 2021; 25:1729-1736. [PMID: 33263892 PMCID: PMC8081685 DOI: 10.1007/s10461-020-03102-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/11/2020] [Indexed: 12/21/2022]
Abstract
The social-ecological model proposes that efforts to modify health behaviors are influenced by constraints and facilitators at multiple levels. We conducted semi-structured interviews with 47 clients in HIV care and 8 HIV clinic staff to explore how such constraints and facilitators (individual, social environment, physical environment, and policies) affect engaging in HIV clinical care in Nakivale Refugee Settlement in Uganda. Thematic analysis revealed that participants were motivated to attend the HIV clinic because of the perceived quality of services and the belief that antiretroviral therapy improves health. Barriers to clinic attendance included distance, cost, unemployment, and climate. Those that disclosed their status had help in overcoming barriers to HIV care. Nondisclosure and stigma disrupted community support in overcoming these obstacles. Interventions to facilitate safe disclosure, mobilize social support, and provide more flexible HIV services may help overcome barriers to HIV care in this setting.
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Affiliation(s)
- Kelli N O'Laughlin
- Departments of Emergency Medicine and Global Health, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA.
| | - Kelsy Greenwald
- Harvard Affiliated Emergency Medicine Residency, Boston, MA, USA
| | | | | | | | - Alexander C Tsai
- Mbarara University of Science and Technology, Mbarara, Uganda
- Center for Global Health, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Norma C Ware
- Harvard Medical School, Boston, MA, USA
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Andrew Kambugu
- Makerere University, Infectious Diseases Institute, Kampala, Uganda
| | - Ingrid V Bassett
- Center for Global Health, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
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Okere NE, Censi V, Machibya C, Costigan K, Katambi P, Martelli G, de Klerk J, Hermans S, Gomez GB, Pozniak A, de Wit TR, Naniche D. Beyond viral suppression: Quality of life among stable ART clients in a differentiated service delivery intervention in Tanzania. Qual Life Res 2021; 31:159-170. [PMID: 34052956 PMCID: PMC8800900 DOI: 10.1007/s11136-021-02889-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/18/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND With antiretroviral therapy, more people living with HIV (PLHIV) in resource-limited settings are virally suppressed and living longer. WHO recommends differentiated service delivery (DSD) as an alternative, less resource-demanding way of expanding HIV services access. Monitoring client's health-related quality of life (HRQoL) is necessary to understand patients' perceptions of treatment and services but is understudied in sub-Saharan Africa. We assessed HRQoL among ART clients in Tanzania accessing two service models. METHODS Cross-sectional survey from May-August 2019 among stable ART clients randomly sampled from clinics and clubs in the Shinyanga region providing DSD and clinic-based care. HRQoL data were collected using a validated HIV-specific instrument-Functional Assessment of HIV infection (FAHI), in addition to socio-demographic, HIV care, and service accessibility data. Descriptive analysis of HRQoL, logistic regression and a stepwise multiple linear regression were performed to examine HRQoL determinants. RESULTS 629 participants were enrolled, of which 40% accessed DSD. Similar HRQoL scores [mean (SD), p-value]; FAHI total [152.2 (22.2) vs 153.8 (20.6), p 0.687] were observed among DSD and clinic-based care participants. Accessibility factors contributed more to emotional wellbeing among DSD participants compared to the clinic-based care participants (53.4% vs 18.5%, p = < 0.001). Satisfactory (> 80% of maximum score) HRQoL scoring was associated with (OR [95% CI], p-value) being male (2.59 [1.36-4.92], p 0.004) among clinic participants and with urban residence (4.72 [1.70-13.1], p 0.001) among DSD participants. CONCLUSIONS Similar HRQoL was observed in DSD and clinic-based care. Our research highlights focus areas to identify supporting interventions, ultimately optimizing HRQoL among PLHIV.
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Affiliation(s)
- Nwanneka Ebelechukwu Okere
- Department of Global Health, Amsterdam Institute for Global Health and Development, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands.
| | - Veronica Censi
- Doctors with Africa (CUAMM), Test & Treat Project Shinyanga, Shinyanga, Tanzania
| | | | - Kathleen Costigan
- Bugisi Health Centre, Catholic Diocese of Shinyanga, Shinyanga, Tanzania
| | - P Katambi
- Ngokolo Health Centre, Catholic Diocese of Shinyanga, Shinyanga, Tanzania
| | - Giulia Martelli
- Doctors with Africa (CUAMM), Test & Treat Project Shinyanga, Shinyanga, Tanzania
| | - Josien de Klerk
- Department of Global Health, Amsterdam Institute for Global Health and Development, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Sabine Hermans
- Department of Global Health, Amsterdam Institute for Global Health and Development, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Gabriela B Gomez
- Department of Global Health and Development London School of Health and Tropical Medicine United Kingdom, London, UK
| | - Anton Pozniak
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Tobias Rinke de Wit
- Department of Global Health, Amsterdam Institute for Global Health and Development, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Denise Naniche
- Barcelona Institute for Global Health, University of Barcelona, Barcelona, Spain
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Cassidy T, Grimsrud A, Keene C, Lebelo K, Hayes H, Orrell C, Zokufa N, Mutseyekwa T, Voget J, Gerstenhaber R, Wilkinson L. Twenty-four-month outcomes from a cluster-randomized controlled trial of extending antiretroviral therapy refills in ART adherence clubs. J Int AIDS Soc 2021; 23:e25649. [PMID: 33340284 PMCID: PMC7749539 DOI: 10.1002/jia2.25649] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 11/16/2020] [Accepted: 11/17/2020] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION The antiretroviral therapy (ART) adherence club (AC) model has supported clinically stable HIV patients' retention with group ART refills and psychosocial support. Reducing visit frequency by increasing ART refills to six months could further benefit patients and unburden health systems. We conducted a pragmatic non-inferiority cluster randomized trial comparing standard of care (SoC) ACs and six-month refill intervention ACs in a primary care facility in Khayelitsha, South Africa. METHODS Existing community-based and facility-based ACs were randomized to either SoC or intervention ACs. SoC ACs met five times annually, receiving two-month refills with a four-month refill over year-end. Blood was drawn at one AC visit with a clinical assessment at the next. Intervention ACs met twice annually receiving six-month refills, with an individual blood collection visit before the annual clinical assessment AC visit. The first study visits were in October and November 2017 and participants followed for 27 months. We report retention in care, viral load completion and viral suppression (<400 copies/mL) 24 months after enrolment and calculated intention-to-treat risk differences for the primary outcomes using generalized estimating equations specifying for clustering by AC. RESULTS Of 2150 participants included in the trial, 977 were assigned to the intervention arm (40 ACs) and 1173 to the SoC (48 ACs). Patient characteristics at enrolment were similar across groups. Retention in care at 24 months was similarly high in both arms: 93.6% (1098/1173) in SoC and 92.6% (905/977) in the intervention arm, with a risk difference of -1.0% (95% CI: -3.2 to 1.3). The intervention arm had higher viral load completion (90.8% (999/1173) versus 85.1% (887/977)) and suppression (87.3% (969 /1173) versus 82.6% (853/977)) at 24 months, with a risk difference for completion of 5.5% (95% CI: 1.5 to 9.5) and suppression of 4.6% (95% CI: 0.2 to 9.0). CONCLUSIONS Intervention AC patients receiving six-month ART refills showed non-inferior retention in care, viral load completion and viral load suppression to those in SoC ACs, adding to a growing literature showing good outcomes with extended ART dispensing intervals.
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Affiliation(s)
- Tali Cassidy
- Médecins Sans Frontières, Khayelitsha, South Africa.,Department of Public Health Medicine, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Claire Keene
- Médecins Sans Frontières, Khayelitsha, South Africa
| | | | - Helen Hayes
- Western Cape Government Department of Health, Cape Town, South Africa
| | - Catherine Orrell
- Department of Medicine, Faculty of Health Sciences, Cape Town, South Africa.,The Desmond Tutu HIV Centre, Institute for Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | | | | | - Jacqueline Voget
- Western Cape Government Department of Health, Cape Town, South Africa
| | | | - Lynne Wilkinson
- International AIDS Society, Cape Town, South Africa.,Center for Infectious Disease and Epidemiological Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
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Abstract
The rising global burden of chronic non-communicable diseases (NCDs) has put a strain on healthcare systems globally, especially in low- and middle-income countries, which have seen disproportionate mortality rates due to non-communicable diseases. These deaths are in part due to challenges with medication adherence, which are compounded by lack of access to medication and weak community support systems. This paper aims to propose a potential solution using models of service delivery in HIV/AIDS, given the many similarities between NCD and HIV/AIDS. Models that have been particularly effective in HIV/AIDS are the community-based peer-support medication delivery groups: medication adherence clubs and community antiretroviral therapy (ART) groups. The positive outcomes from these models, including improved medication adherence and patient satisfaction, provide evidence for their potential success when applied to non-communicable diseases, particularly hypertension and cardiovascular disease.
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31
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Ehrenkranz P, Rosen S, Boulle A, Eaton JW, Ford N, Fox MP, Grimsrud A, Rice BD, Sikazwe I, Holmes CB. The revolving door of HIV care: Revising the service delivery cascade to achieve the UNAIDS 95-95-95 goals. PLoS Med 2021; 18:e1003651. [PMID: 34029346 PMCID: PMC8186775 DOI: 10.1371/journal.pmed.1003651] [Citation(s) in RCA: 65] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Revised: 06/08/2021] [Indexed: 01/01/2023] Open
Abstract
Peter Ehrenkranz and co-authors present a cyclical cascade of care for people with HIV infection, aiming to facilitate assessment of outcomes.
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Affiliation(s)
- Peter Ehrenkranz
- Global Health, Bill & Melinda Gates Foundation, Seattle, WA, United States of America
- * E-mail:
| | - Sydney Rosen
- Department of Global Health, Boston University School of Public Health, Boston, MA, United States of America
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Andrew Boulle
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Jeffrey W. Eaton
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, United Kingdom
| | - Nathan Ford
- HIV & Global Hepatitis Programme, World Health Organization, Geneva, Switzerland
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Matthew P. Fox
- Department of Global Health, Boston University School of Public Health, Boston, MA, United States of America
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, United States of America
| | - Anna Grimsrud
- HIV Programmes & Advocacy Department, International AIDS Society, Cape Town, South Africa
| | - Brian D. Rice
- Department of Public Health, Environments and Society, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Izukanji Sikazwe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Charles B. Holmes
- Center for Innovation in Global Health, Georgetown University, Washington, DC, United States of America
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Ravicz M, Muhongayire B, Kamagaju S, Klabbers RE, Faustin Z, Kambugu A, Bassett I, O'Laughlin K. Using Intervention Mapping methodology to design an HIV linkage intervention in a refugee settlement in rural Uganda. AIDS Care 2021; 34:446-458. [PMID: 33749418 PMCID: PMC8452793 DOI: 10.1080/09540121.2021.1900532] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Nearly 80 million people have been forcibly displaced by persecution, violence, and disaster. Displaced populations, including refugees, face health challenges such as resource shortages, food and housing insecurity, violence, and disrupted social support. People living with HIV in refugee settings have decreased engagement with HIV services compared to non-refugee populations, and interventions are needed to enhance linkage to care. However, designing health interventions in humanitarian settings is challenging. We used Intervention Mapping (IM), a six-step method for developing theory- and evidence-based health interventions, to design a program to increase linkage to HIV care for refugees and Ugandan nationals in Nakivale Refugee Settlement in Uganda. We engaged a diverse group of stakeholders (N = 14) in Nakivale, including community members and humanitarian actors, in an interactive workshop focusing on IM steps 1–4. We developed a chronic care program that would integrate HIV care with services for hypertension and diabetes at accessible community sites, thereby decreasing stigma around HIV treatment and improving access to care. IM provided an inclusive, efficient method for integrating community members and program implementers in the intervention planning process, and can be used as a method-driven approach to intervention design in humanitarian settings.
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Affiliation(s)
- Miranda Ravicz
- Departments of Internal Medicine and Pediatrics, Massachusetts General Hospital, Boston, MA, USA
| | | | | | - Robin E Klabbers
- Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands
| | | | - Andrew Kambugu
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Ingrid Bassett
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Kelli O'Laughlin
- Departments of Emergency Medicine and Global Health, University of Washington, Seattle, WA, USA
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Giovenco D, Gill K, Fynn L, Duyver M, O’Rourke S, van der Straten A, Morton JF, Celum CL, Bekker LG. Experiences of oral pre-exposure prophylaxis (PrEP) use disclosure among South African adolescent girls and young women and its perceived impact on adherence. PLoS One 2021; 16:e0248307. [PMID: 33667264 PMCID: PMC7935254 DOI: 10.1371/journal.pone.0248307] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 02/23/2021] [Indexed: 01/22/2023] Open
Abstract
INTRODUCTION There is limited understanding of how social dynamics impact pre-exposure prophylaxis (PrEP) adherence among adolescent girls and young women (AGYW) in generalized HIV-epidemic settings. We examined experiences of oral PrEP use disclosure to various social groups with the goal of identifying supportive relationships that can be leveraged to promote adherence. METHODS We used qualitative methods to explore experiences disclosing PrEP use and the perceived impact of disclosure on adherence among 22 South African AGYW (16-25 years) taking daily oral PrEP. Serial in-depth-interviews (IDIs) were conducted 1-, 3-, and 12-months post-PrEP initiation. Respondents also self-reported their disclosures separately for various social groups and adherence was assessed using intracellular tenofovir-diphosphate levels. RESULTS Qualitative respondents had a median age of 20.5 years and reported disclosing their PrEP use to friends (n = 36 total disclosures), partners, siblings, other family members (n = 24 disclosures each), and parents (n = 19 disclosures). IDI data revealed that parents and partners provided the most support to respondents and a lack of support from these groups was most often perceived as negatively affecting PrEP use. AGYW described difficulties explaining PrEP to their mothers, who believed PrEP was HIV treatment or would lead to HIV infection. Disclosure to household members was notably meaningful for AGYW (both positively and negatively). Respondents reported leveraging supportive relationships for pill reminders. For respondents who perceived a household member would be unsupportive, however, non-disclosure was less feasible and PrEP use was often stigmatized. To avoid stigma, several respondents hid or discontinued PrEP. CONCLUSIONS While supportive relationships may facilitate PrEP use, disclosure can also lead to stigma. Counselors should support AGYW in disclosing to key people in their social networks and provide AGYW with materials that lend credibility to explanations of PrEP. Community education is necessary to alleviate PrEP-related stigma and facilitate disclosure.
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Affiliation(s)
- Danielle Giovenco
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
- The Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Katherine Gill
- The Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Lauren Fynn
- The Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Menna Duyver
- The Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Shannon O’Rourke
- RTI International, Women’s Global Health Imperative, Berkeley, CA, United States of America
| | - Ariane van der Straten
- RTI International, Women’s Global Health Imperative, Berkeley, CA, United States of America
- Center for AIDS Prevention Studies, Department of Medicine, UCSF, San Francisco, CA, United States of America
| | - Jennifer F. Morton
- Department of Global Health, University of Washington, Seattle, WA, United States of America
| | - Connie L. Celum
- Department of Global Health, University of Washington, Seattle, WA, United States of America
- Departments of Medicine and Epidemiology, University of Washington, Seattle, WA, United States of America
| | - Linda-Gail Bekker
- The Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
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Kusemererwa S, Akena D, Nakanjako D, Kigozi J, Nanyunja R, Nanfuka M, Kizito B, Okello JM, Sewankambo NK. Strategies for retention of heterosexual men in HIV care in sub-Saharan Africa: A systematic review. PLoS One 2021; 16:e0246471. [PMID: 33539424 PMCID: PMC7861356 DOI: 10.1371/journal.pone.0246471] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 01/19/2021] [Indexed: 11/18/2022] Open
Abstract
Expansion of Antiretroviral Therapy (ART) programs in sub-Saharan Africa (SSA) has increased the number of people accessing treatment. However, the number of males accessing and being retained along the human immunodeficiency virus (HIV) care cascade is significantly below the UNAIDS target. Male gender has been associated with poor retention in HIV care programs, and little is known about strategies that reduce attrition of men in ART programs. This review aimed to summarize any studies on strategies to improve retention of heterosexual males in HIV care in SSA. An electronic search was conducted through Ovid® for three databases (MEDLINE®, Embase and Global Health). Studies reporting interventions aimed at improving retention among heterosexual men along the HIV care cascade were reviewed. The inclusion criteria included randomized-controlled trials (RCTs), prospective or retrospective cohort studies that studied adult males (≥15years of age), conducted in SSA and published between January 2005 and April 2019 with an update from 2019 to 2020. The search returned 1958 articles, and 14 studies from eight countries met the inclusion criteria were presented using the PRISMA guidelines. A narrative synthesis was conducted. Six studies explored community-based adherence support groups while three compared use of facility versus community-based delivery models. Three studies measured the effect of national identity cards, disclosure of HIV status, six-monthly clinic visits and distance from the health center. Four studies measured risk of attrition from care using hazard ratios ranging from 1.2–1.8, four studies documented attrition proportions at an average of 40.0% and two studies an average rate of attrition of 43.4/1000PYs. Most (62%) included studies were retrospective cohorts, subject to risk of allocation and outcome assessment bias. A pooled analysis was not performed because of heterogeneity of studies and outcome definitions. No studies have explored heterosexual male- centered interventions in HIV care. However, in included studies that explored retention in both males and females, there were high rates of attrition in males. More male-centered interventions need to be studied preferably in RCTs. Registry number: PROSPERO2020 CRD42020142923 Available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020142923.
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Affiliation(s)
- Sylvia Kusemererwa
- Department of HIV Interventions, Medical Research Council/Uganda Virus Research Institute (MRC/UVRI) and London School of Hygiene and Tropical Medicine (LSHTM), Uganda Research Unit, Entebbe, Uganda
- * E-mail: ,
| | - Dickens Akena
- Department of Psychiatry, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Damalie Nakanjako
- Department of Medicine, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Joanita Kigozi
- Department for Outreaches, Infectious Diseases Institute (IDI), Makerere University College of Health Sciences, Kampala, Uganda
| | - Regina Nanyunja
- Department of HIV Interventions, Medical Research Council/Uganda Virus Research Institute (MRC/UVRI) and London School of Hygiene and Tropical Medicine (LSHTM), Uganda Research Unit, Entebbe, Uganda
| | - Mastula Nanfuka
- Department of TBSpeed, Makerere University Johns Hopkins University Research Collaboration (MUJHU), Kampala, Uganda
| | - Bennet Kizito
- Department of Monitoring and Evaluation, The AIDS Support Organization (TASO), Kampala, Uganda
| | - Joseph Mugisha Okello
- Department of HIV Interventions, Medical Research Council/Uganda Virus Research Institute (MRC/UVRI) and London School of Hygiene and Tropical Medicine (LSHTM), Uganda Research Unit, Entebbe, Uganda
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Limbada M, Bwalya C, Macleod D, Floyd S, Schaap A, Situmbeko V, Hayes R, Fidler S, Ayles H. A comparison of different community models of antiretroviral therapy delivery with the standard of care among stable HIV+ patients: rationale and design of a non-inferiority cluster randomized trial, nested in the HPTN 071 (PopART) study. Trials 2021; 22:52. [PMID: 33430928 PMCID: PMC7802215 DOI: 10.1186/s13063-020-05010-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 12/29/2020] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Following the World Health Organization's (WHO) 2015 guidelines recommending initiation of antiretroviral therapy (ART) irrespective of CD4 count for all people living with HIV (PLHIV), many countries in sub-Saharan Africa have adopted this strategy to reach epidemic control. As the number of PLHIV on ART rises, maintenance of viral suppression on ART for over 90% of PLHIV remains a challenge to government health systems in resource-limited high HIV burden settings. Non facility-based antiretroviral therapy (ART) delivery for stable HIV+ patients may increase sustainable ART coverage in resource-limited settings. Within the HPTN 071 (PopART) trial, two models, home-based delivery (HBD) or adherence clubs (AC), were offered to assess whether they achieved similar viral load suppression (VLS) to standard of care (SoC). In this paper, we describe the trial design and discuss the methodological issues and challenges. METHODS A three-arm cluster randomized non-inferiority trial, nested in two urban HPTN 071 trial communities in Zambia, randomly allocated 104 zones to SoC (35), HBD (35), or AC (34). ART and adherence support were delivered 3-monthly at home (HBD), adherence clubs (AC), or clinic (SoC). Adult HIV+ patients defined as "stable" on ART were eligible for inclusion. The primary endpoint was the proportion of PLHIV with virological suppression (≤ 1000 copies HIV RNA/ml) at 12 months (± 3months) after study entry across all three arms. Viral load measurement was done at the routine government laboratories in accordance with national guidelines, annually. The study was powered to determine if either of the community-based interventions would yield a viral suppression rate drop compared to SoC of no more than 5% in its absolute value. Both community-based interventions were delivered by community HIV providers (CHiPs). An additional qualitative study using observations, interviews with PLHIV, and FGDs with community HIV providers was nested in this study to complement the quantitative data. DISCUSSION This trial was designed to provide rigorous randomized evidence of safety and efficacy of non-facility-based delivery of ART for stable PLHIV in high-burden resource-limited settings. This trial will inform policy regarding best practices and what is needed to strengthen scale-up of differentiated models of ART delivery in resource-limited settings. TRIAL REGISTRATION ClinicalTrials.gov NCT03025165 . Registered on 19 January 2017.
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Affiliation(s)
- Mohammed Limbada
- Zambart, University of Zambia, School of Medicine, Zambart House, Ridgeway Campus, Off Nationalist Road, P.O. Box 50697, Lusaka, Zambia.
| | - Chiti Bwalya
- Zambart, University of Zambia, School of Medicine, Zambart House, Ridgeway Campus, Off Nationalist Road, P.O. Box 50697, Lusaka, Zambia
| | - David Macleod
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Sian Floyd
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Ab Schaap
- Zambart, University of Zambia, School of Medicine, Zambart House, Ridgeway Campus, Off Nationalist Road, P.O. Box 50697, Lusaka, Zambia
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Vasty Situmbeko
- Zambart, University of Zambia, School of Medicine, Zambart House, Ridgeway Campus, Off Nationalist Road, P.O. Box 50697, Lusaka, Zambia
| | - Richard Hayes
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Sarah Fidler
- Imperial College and Imperial College NIHR BRC, London, UK
| | - Helen Ayles
- Zambart, University of Zambia, School of Medicine, Zambart House, Ridgeway Campus, Off Nationalist Road, P.O. Box 50697, Lusaka, Zambia
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
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Chauke P, Huma M, Madiba S. Lost to follow up rate in the first year of ART in adults initiated in a universal test and treat programme: a retrospective cohort study in Ekurhuleni District, South Africa. Pan Afr Med J 2020; 37:198. [PMID: 33505567 PMCID: PMC7813655 DOI: 10.11604/pamj.2020.37.198.25294] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Accepted: 09/26/2020] [Indexed: 12/03/2022] Open
Abstract
Introduction South Africa adopted and implemented the Universal Test and Treat (UTT) strategy for HIV since 2016. However, the care outcomes for patients initiated antiretroviral therapy (ART) through the UTT strategy have not been established. We determined the rate of lost to follow up (LTFU) and associated factors in patients who were initiated on ART through the UTT and the pre-ART strategy at 12 months post ART initiation. Methods this retrospective study analyzed the records of a cohort of patients at 12 months post the initiation of ART. We extracted data from the TIER.Net electronic database of selected facilities in a sub-district in Gauteng Province, South Africa. Factors associated with LFTU at 12 months of ART were assessed and logistic regression performed to identify predictors of LFTU. Results records of 367 patients were evaluated, and 54% were initiated ART through the UTT strategy. The mean age was 36.3 years, mean CD4 cell count at ART initiation was 341 cells/mm3, and 25% were initiated at CD4 cell count above 500 cells/mm3. LTFU at 12 months was 28%, 50% were LFTU within six months, and 28% within three months of ART. LFTU in the UTT cohort was higher than in the pre-ART cohort, patients initiated through UTT were twice more likely to be LTFU (AOR = 1.84, CI: 1.13-3.00) than pre-ART patients. Conclusion the rate of LTFU at 12 months of ART was 28%, which indicate that the retention in care rate (60%) falls far short of the triple 90 targets required for viral suppression.
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Affiliation(s)
- Patricia Chauke
- Department of Public Health, School of Health Care Sciences, Sefako Makgatho Health Sciences University, Pretoria, South Africa
| | - Mmampedi Huma
- Department of Public Health, School of Health Care Sciences, Sefako Makgatho Health Sciences University, Pretoria, South Africa
| | - Sphiwe Madiba
- Department of Public Health, School of Health Care Sciences, Sefako Makgatho Health Sciences University, Pretoria, South Africa
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Finci I, Flores A, Gutierrez Zamudio AG, Matsinhe A, de Abreu E, Issufo S, Gaspar I, Ciglenecki I, Molfino L. Outcomes of patients on second- and third-line ART enrolled in ART adherence clubs in Maputo, Mozambique. Trop Med Int Health 2020; 25:1496-1502. [PMID: 32959934 PMCID: PMC7756444 DOI: 10.1111/tmi.13490] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Objectives Adherence clubs (AC) offer patient‐centred access to antiretroviral therapy (ART) while reducing the burden on health facilities. AC were implemented in a health centre in Mozambique specialising in patients with a history of HIV treatment failure. We explored the impact of AC on retention in care and VL suppression of these patients. Methods We performed a retrospective analysis of patients enrolled in AC receiving second‐ or third‐line ART. The Kaplan–Meier estimates were used to analyse retention in care in health facility, retention in AC and viral load (VL) suppression (VL < 1000 copies/mL). Predictors of attrition and VL rebound (VL ≥ 1000 copies/mL) were assessed using multivariable proportional hazards regression. Results The analysed cohort contained 699 patients, median age 40 years [IQR: 35–47], 428 (61%) female and 97% second‐line ART. Overall, 9 (1.3%) patients died, and 10 (1.4%) were lost to follow‐up. Retention in care at months 12 and 24 was 98.9% (95% CI: 98.2–99.7) and 96.4% (95% CI: 94.6–98.2), respectively. Concurrently, 85.8% (95% CI: 83.1–88.2) and 80.9% (95% CI: 77.8–84.1) of patients maintained VL suppression. No association between predictors and all‐cause attrition or VL rebound was detected. Among 90 patients attending AC and simultaneously having VL rebound, 64 (71.1%) achieved VL resuppression, 10 (11.1%) did not resuppress, and 14 (15.6%) had no subsequent VL result. Conclusion Implementation of AC in Mozambique was successful and demonstrated that patients with a history of HIV treatment failure can be successfully retained in care and have high VL suppression rate when enrolled in AC. Expansion of the AC model in Mozambique could improve overall retention in care and VL suppression while reducing workload in health facilities.
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Affiliation(s)
- I Finci
- Médecins sans Frontières, Maputo, Mozambique
| | - A Flores
- Médecins sans Frontières, Maputo, Mozambique
| | | | - A Matsinhe
- Médecins sans Frontières, Maputo, Mozambique
| | - E de Abreu
- Médecins sans Frontières, Maputo, Mozambique
| | - S Issufo
- Ministry of Health, Maputo, Mozambique
| | - I Gaspar
- Ministry of Health, Maputo, Mozambique
| | | | - L Molfino
- Médecins sans Frontières, Maputo, Mozambique
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Mendelsohn AS, Ritchwood T. COVID-19 and Antiretroviral Therapies: South Africa's Charge Towards 90-90-90 in the Midst of a Second Pandemic. AIDS Behav 2020; 24:2754-2756. [PMID: 32356032 PMCID: PMC7191543 DOI: 10.1007/s10461-020-02898-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Zerbe A, Brittain K, Phillips TK, Iyun VO, Allerton J, Nofemela A, Kalombo CD, Myer L, Abrams EJ. Community-based adherence clubs for postpartum women on antiretroviral therapy (ART) in Cape Town, South Africa: a pilot study. BMC Health Serv Res 2020; 20:621. [PMID: 32641032 PMCID: PMC7341610 DOI: 10.1186/s12913-020-05470-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 06/25/2020] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND With an increasing number of countries implementing Option B+ guidelines of lifelong antiretroviral therapy (ART) for all pregnant and breastfeeding women, there is urgent need to identify effective approaches for retaining this growing and highly vulnerable population in ART care. METHODS Newly postpartum, breastfeeding women who initiated ART in pregnancy and met eligibility criteria were enrolled, and offered the choice of two options for postpartum ART care: (i) referral to existing network of community-based adherence clubs or (ii) referral to local primary health care clinic (PHC). Women were followed at study measurement visits conducted separately from either service. Primary outcome was a composite endpoint of retention in ART services and viral suppression [VS < 50 copies/mL based on viral load (VL) testing at measurement visits] at 12 months postpartum. Outcomes were compared across postpartum services using chi-square, Fisher's exact tests and Poisson regression models. The primary outcome was compared across services where women were receiving care at 12 months postpartum in exploratory analyses. RESULTS Between February and September 2015, 129 women (median age: 28.9 years; median time postpartum: 10 days) were enrolled with 65% opting to receive postpartum HIV care through an adherence club. Among 110 women retained at study measurement visits, 91 (83%) achieved the composite endpoint, with no difference between those who originally chose clubs versus those who chose PHC services. Movement from an adherence club to PHC services was common: 31% of women who originally chose clubs and were engaged in care at 12 months postpartum were attending a PHC service. Further, levels of VS differed significantly by where women were accessing ART care at 12 months postpartum, regardless of initial choice: 98% of women receiving care in an adherence club and 76% receiving care at PHC had VS < 50 copies/mL at 12 months postpartum (p = 0.001). CONCLUSION This study found comparable outcomes related to retention and VS at 12 months postpartum between women choosing adherence clubs and those choosing PHC. However, movement between postpartum services among those who originally chose adherence clubs was common, with poorer VS outcomes among women leaving clubs and returning to PHC services. TRIAL REGISTRATION ClinicalTrials.gov NCT02417675 , April 16, 2015 (retrospectively registered).
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Affiliation(s)
- Allison Zerbe
- ICAP, Mailman School of Public Health, Columbia University, 722 W. 168th street, 13th floor, New York, 10032 USA
| | - Kirsty Brittain
- Centre for Infectious Disease Epidemiology & Research, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Tamsin K. Phillips
- Centre for Infectious Disease Epidemiology & Research, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Victoria O. Iyun
- Centre for Infectious Disease Epidemiology & Research, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Joanna Allerton
- Centre for Infectious Disease Epidemiology & Research, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Andile Nofemela
- Centre for Infectious Disease Epidemiology & Research, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Cathy D. Kalombo
- Provincial Government of the Western Cape, Cape Town, South Africa
| | - Landon Myer
- Centre for Infectious Disease Epidemiology & Research, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Elaine J. Abrams
- ICAP, Mailman School of Public Health, Columbia University, 722 W. 168th street, 13th floor, New York, 10032 USA
- Vagelos College of Physicians & Surgeons, Columbia University, New York, USA
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Roy M, Bolton-Moore C, Sikazwe I, Mukumbwa-Mwenechanya M, Efronson E, Mwamba C, Somwe P, Kalunkumya E, Lumpa M, Sharma A, Pry J, Mutale W, Ehrenkranz P, Glidden DV, Padian N, Topp S, Geng E, Holmes CB. Participation in adherence clubs and on-time drug pickup among HIV-infected adults in Zambia: A matched-pair cluster randomized trial. PLoS Med 2020; 17:e1003116. [PMID: 32609756 PMCID: PMC7329062 DOI: 10.1371/journal.pmed.1003116] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 05/27/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Current models of HIV service delivery, with frequent facility visits, have led to facility congestion, patient and healthcare provider dissatisfaction, and suboptimal quality of services and retention in care. The Zambian urban adherence club (AC) is a health service innovation designed to improve on-time drug pickup and retention in HIV care through off-hours facility access and pharmacist-led group drug distribution. Similar models of differentiated service delivery (DSD) have shown promise in South Africa, but observational analyses of these models are prone to bias and confounding. We sought to evaluate the effectiveness and implementation of ACs in Zambia using a more rigorous study design. METHODS AND FINDINGS Using a matched-pair cluster randomized study design (ClinicalTrials.gov: NCT02776254), 10 clinics were randomized to intervention (5 clinics) or control (5 clinics). At each clinic, between May 19 and October 27, 2016, a systematic random sample was assessed for eligibility (HIV+, age ≥ 14 years, on ART >6 months, not acutely ill, CD4 count not <200 cells/mm3) and willingness to participate in an AC. Clinical and antiretroviral drug pickup data were obtained through the existing electronic medical record. AC meeting attendance data were collected at intervention facilities prospectively through October 28, 2017. The primary outcome was time to first late drug pickup (>7 days late). Intervention effect was estimated using unadjusted Kaplan-Meier survival curves and a Cox proportional hazards model to derive an adjusted hazard ratio (aHR). Medication possession ratio (MPR) and implementation outcomes (adoption, acceptability, appropriateness, feasibility, and fidelity) were additionally evaluated as secondary outcomes. Baseline characteristics were similar between 571 intervention and 489 control participants with respect to median age (42 versus 41 years), sex (62% versus 66% female), median time since ART initiation (4.8 versus 5.0 years), median CD4 count at study enrollment (506 versus 533 cells/mm3), and baseline retention (53% versus 55% with at least 1 late drug pickup in previous 12 months). The rate of late drug pickup was lower in intervention participants compared to control participants (aHR 0.26, 95% CI 0.15-0.45, p < 0.001). Median MPR was 100% in intervention participants compared to 96% in control participants (p < 0.001). Although 18% (683/3,734) of AC group meeting visits were missed, on-time drug pickup (within 7 days) still occurred in 51% (350/683) of these missed visits through alternate means (use of buddy pickup or early return to the facility). Qualitative evaluation suggests that the intervention was acceptable to both patients and providers. While patients embraced the convenience and patient-centeredness of the model, preference for traditional adherence counseling and need for greater human resources influenced intervention appropriateness and feasibility from the provider perspective. The main limitations of this study were the small number of clusters, lack of viral load data, and relatively short follow-up period. CONCLUSIONS ACs were found to be an effective model of service delivery for reducing late ART drug pickup among HIV-infected adults in Zambia. Drug pickup outside of group meetings was relatively common and underscores the need for DSD models to be flexible and patient-centered if they are to be effective. TRIAL REGISTRATION ClinicalTrials.gov NCT02776254.
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Affiliation(s)
- Monika Roy
- University of California, San Francisco, San Fancisco, California, United States of America
| | - Carolyn Bolton-Moore
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- University of Alabama, Tuscaloosa, Alabama, United States of America
| | - Izukanji Sikazwe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | | | - Emilie Efronson
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Chanda Mwamba
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Paul Somwe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | | | - Mwansa Lumpa
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Anjali Sharma
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Jake Pry
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- University of California, Davis, Davis, California, United States of America
| | - Wilbroad Mutale
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Peter Ehrenkranz
- Bill and Melinda Gates Foundation, Seattle, Washington, United States of America
| | - David V. Glidden
- University of California, San Francisco, San Fancisco, California, United States of America
| | - Nancy Padian
- University of California, Berkeley, Berkeley, California, United States of America
| | - Stephanie Topp
- James Cook University, Townsville, Queensland, Australia
| | - Elvin Geng
- University of California, San Francisco, San Fancisco, California, United States of America
| | - Charles B. Holmes
- Johns Hopkins University, Baltimore, Maryland, United States of America
- Center for Global Health Practice and Impact, Georgetown University School of Medicine, Washington, District of Columbia, United States of America
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Larson BA, Pascoe SJ, Huber A, Long LC, Murphy J, Miot J, Fox MP, Fraser-Hurt N, Rosen S. Will differentiated care for stable HIV patients reduce healthcare systems costs? J Int AIDS Soc 2020; 23:e25541. [PMID: 32686911 PMCID: PMC7370539 DOI: 10.1002/jia2.25541] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 04/17/2020] [Accepted: 05/07/2020] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION South Africa's National Department of Health launched the National Adherence Guidelines for Chronic Diseases in 2015. These guidelines include adherence clubs (AC) and decentralized medication delivery (DMD) as two differentiated models of care for stable HIV patients on antiretroviral therapy. While the adherence guidelines do not suggest that provider costs (costs to the healthcare system for medications, laboratory tests and visits to clinics or alternative locations) for stable patients in these differentiated models of care will be lower than conventional, clinic-based care, recent modelling exercises suggest that such differentiated models could substantially reduce provider costs. In the context of continued implementation of the guidelines, we discuss the conditions under which provider costs of care for stable HIV patients could fall, or rise, with AC and DMD models of care in South Africa. DISCUSSION In prior studies of HIV care and treatment costs, three main cost categories are antiretroviral medications, laboratory tests and general interaction costs based on encounters with health workers. Stable patients are likely to be on the national first-line regimen (Tenofovir/Entricitabine/Efavarinz (TDF/FTC/EFV)), so no difference in the costs of medications is expected. Laboratory testing guidelines for stable patients are the same regardless of the model of care, so no difference in laboratory costs is expected as well. Based on existing information regarding the costs of clinic visits, AC visits and DMD drug pickups, we expect that for some clinics, visit costs for DMD or AC models of care could be less, but modestly so, than for conventional, clinic-based care. For other clinics, however, DMD or AC models could have higher visit costs (see Table 2). CONCLUSIONS The standard of care for stable patients has already been "differentiated" for years in South Africa, prior to the roll out of the new adherence guidelines. AC and DMD models of care, when implemented as envisioned in the guidelines, are unlikely to generate substantive reductions or increases in provider costs of care.
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Affiliation(s)
- Bruce A Larson
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | - Sophie Js Pascoe
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Amy Huber
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Lawrence C Long
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Joshua Murphy
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Jacqui Miot
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Matthew P Fox
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | | | - Sydney Rosen
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Dessie ZG, Zewotir T, Mwambi H, North D. Modeling Viral Suppression, Viral Rebound and State-Specific Duration of HIV Patients with CD4 Count Adjustment: Parametric Multistate Frailty Model Approach. Infect Dis Ther 2020; 9:367-388. [PMID: 32318999 PMCID: PMC7237593 DOI: 10.1007/s40121-020-00296-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION Combination antiretroviral therapy has become the standard care of human immunodeficiency virus (HIV)-infected patients and has further led to a dramatically decreased progression probability to acquired immune deficiency syndrome (AIDS) for patients under such a therapy. However, responses of the patients to this therapy have recorded heterogeneous complexity and high dynamism. In this paper, we simultaneously model long-term viral suppression, viral rebound, and state-specific duration of HIV-infected patients. METHODS Full-parametric and semi-parametric Markov multistate models were applied to assess the effects of covariates namely TB co-infection, educational status, marital status, age, quality of life (QoL) scores, white and red blood cell parameters, and liver enzyme abnormality on long-term viral suppression, viral rebound and state-specific duration for HIV-infected individuals before and after treatment. Furthermore, two models, one including and another excluding the effect of the frailty, were presented and compared in this study. RESULTS Results from the diagnostic plots, Akaike information criterion (AIC) and likelihood ratio test showed that the Weibull multistate frailty model fitted significantly better than the exponential and semi-parametric multistate models. Viral rebound was found to be significantly associated with many sex partners, higher eosinophils count, younger age, lower educational level, higher monocyte counts, having abnormal neutrophils count, and higher liver enzyme abnormality. Furthermore, viral suppression was also found to be significantly associated with higher QoL scores, and having a stable sex partner. The analysis result also showed that patients with a stable sex partner, higher educational levels, higher QoL scores, lower eosinophils count, lower monocyte counts, and higher RBC indices were more likely to spend more time in undetectable viral load state. CONCLUSIONS To achieve and maintain the UNAIDS 90% suppression targets, additional interventions are required to optimize antiretroviral therapy outcomes, specifically targeting those with poor clinical characteristics, lower education, younger age, and those with many sex partners. From a methodological perspective, the parametric multistate approach with frailty is a flexible approach for modeling time-varying variables, allowing for dealing with heterogeneity between the sequence of transitions, as well as allowing for a reasonable degree of flexibility with a few additional parameters, which then aids in gaining a better insight into how factors change over time.
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Affiliation(s)
- Zelalem G Dessie
- School of Mathematics, Statistics and Computer Science, University of KwaZulu-Natal, Durban, South Africa.
- College of Science, Bahir Dar University, Bahir Dar, Ethiopia.
| | - Temesgen Zewotir
- School of Mathematics, Statistics and Computer Science, University of KwaZulu-Natal, Durban, South Africa
| | - Henry Mwambi
- School of Mathematics, Statistics and Computer Science, University of KwaZulu-Natal, Durban, South Africa
| | - Delia North
- School of Mathematics, Statistics and Computer Science, University of KwaZulu-Natal, Durban, South Africa
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Kehoe K, Boulle A, Tsondai PR, Euvrard J, Davies MA, Cornell M. Long-term virologic responses to antiretroviral therapy among HIV-positive patients entering adherence clubs in Khayelitsha, Cape Town, South Africa: a longitudinal analysis. J Int AIDS Soc 2020; 23:e25476. [PMID: 32406983 PMCID: PMC7224308 DOI: 10.1002/jia2.25476] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 02/06/2020] [Accepted: 02/20/2020] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION In South Africa, an estimated 4.6 million people were accessing antiretroviral therapy (ART) in 2018. As universal Test and Treat is implemented, these numbers will continue to increase. Given the need for lifelong care for millions of individuals, differentiated service delivery models for ART services such as adherence clubs (ACs) for stable patients are required. In this study, we describe long-term virologic outcomes of patients who have ever entered ACs in Khayelitsha, Cape Town. METHODS We included adult patients enrolled in ACs in Khayelitsha between January 2011 and December 2016 with a recorded viral load (VL) before enrolment. Risk factors for an elevated VL (VL >1000 copies/mL) and confirmed virologic failure (two consecutive VLs >1000 copies/mL one year apart) were estimated using Cox proportional hazards models. VL completeness over time was assessed. RESULTS Overall, 8058 patients were included in the analysis, contributing 16,047 person-years of follow-up from AC entry (median follow-up time 1.7 years, interquartile range [IQR]:0.9 to 2.9). At AC entry, 74% were female, 46% were aged between 35 and 44 years, and the median duration on ART was 4.8 years (IQR: 3.0 to 7.2). Among patients virologically suppressed at AC entry (n = 8058), 7136 (89%) had a subsequent VL test, of which 441 (6%) experienced an elevated VL (median time from AC entry 363 days, IQR: 170 to 728). Older age (adjusted hazard ratio [aHR] 0.64, 95% confidence interval [CI] 0.46 to 0.88), more recent year of AC entry (aHR 0.76, 95% CI 0.68 to 0.84) and higher CD4 count (aHR 0.67, 95% CI 0.54 to 0.84) were protective against experiencing an elevated VL. Among patients with an elevated VL, 52% (150/291) with a repeat VL test subsequently experienced confirmed virologic failure in a median time of 112 days (IQR: 56 to 168). Frequency of VL testing was constant over time (82 to 85%), with over 90% of patients remaining virologically suppressed. CONCLUSIONS This study demonstrates low prevalence of elevated VLs and confirmed virologic failure among patients who entered ACs. Although ACs were expanded rapidly, most patients were well monitored and remained stable, supporting the continued rollout of this model.
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Affiliation(s)
- Kathleen Kehoe
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
| | - Andrew Boulle
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
- Khayelitsha ART Programme and Médecins Sans FrontièresCape TownSouth Africa
- Health Impact Assessment Provincial Government of the Western CapeCape TownSouth Africa
| | - Priscilla R Tsondai
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
| | - Jonathan Euvrard
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
- Khayelitsha ART Programme and Médecins Sans FrontièresCape TownSouth Africa
| | - Mary Ann Davies
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
- Health Impact Assessment Provincial Government of the Western CapeCape TownSouth Africa
| | - Morna Cornell
- Centre for Infectious Disease Epidemiology and ResearchSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
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Roy M, Bolton Moore C, Sikazwe I, Holmes CB. A Review of Differentiated Service Delivery for HIV Treatment: Effectiveness, Mechanisms, Targeting, and Scale. Curr HIV/AIDS Rep 2020; 16:324-334. [PMID: 31230342 DOI: 10.1007/s11904-019-00454-5] [Citation(s) in RCA: 67] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
PURPOSE OF REVIEW Differentiated service delivery (DSD) models were initially developed as a means to combat suboptimal long-term retention in HIV care, and to better titrate limited health systems resources to patient needs, primarily in low-income countries. The models themselves are designed to streamline care along the HIV care cascade and range from individual to group-based care and facility to community-based health delivery systems. However, much remains to be understood about how well and for whom DSD models work and whether these models can be scaled, are sustainable, and can reach vulnerable and high-risk populations. Implementation science is tasked with addressing some of these questions through systematic, scientific inquiry. We review the available published evidence on the implementation of DSD and suggest further health systems innovations needed to maximize the public health impact of DSD and future implementation science research directions in this expanding field. RECENT FINDINGS While early observational data supported the effectiveness of various DSD models, more recently published trials as well as evaluations of national scale-up provide more rigorous evidence for effectiveness and performance at scale. Deeper understanding of the mechanism of effect of various DSD models and generalizability of studies to other countries or contexts remains somewhat limited. Relative implementability of DSD models may differ based on patient preference, logistical complexity of model adoption and maintenance, human resource and pharmacy supply chain needs, and comparative cost-effectiveness. However, few studies to date have evaluated comparative implementation or cost-effectiveness from a health systems perspective. While DSD represents an exciting and promising "next step" in HIV health care delivery, this innovation comes with its own set of implementation challenges. Evidence on the effectiveness of DSD generally supports the use of most DSD models, although it is still unclear which models are most relevant in diverse settings and populations and which are the most cost-effective. Challenges during scale-up highlight the need for accurate differentiation of patients, sustainable inclusion of a new cadre of health care worker (the community health care worker), and substantial strengthening of existing pharmacy supply chains. To maximize the public health impact of DSD, systems need to be patient-centered and adaptive, as well as employ robust quality improvement processes.
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Affiliation(s)
- Monika Roy
- Division of HIV, Infectious Diseases, and Global Medicine, San Francisco General Hospital, University of California, San Francisco, 995 Potrero Avenue, Bldg 80, San Francisco, CA, 94110, USA.
| | - Carolyn Bolton Moore
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.,University of Alabama, Birmingham, AL, USA
| | - Izukanji Sikazwe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Charles B Holmes
- Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Center for Global Health and Quality, Georgetown University School of Medicine, Washington, DC, USA
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Lejone TI, Kopo M, Bachmann N, Brown JA, Glass TR, Muhairwe J, Matsela T, Scherrer R, Chere L, Namane T, Labhardt ND, Amstutz A. PEBRA trial - effect of a peer-educator coordinated preference-based ART service delivery model on viral suppression among adolescents and young adults living with HIV: protocol of a cluster-randomized clinical trial in rural Lesotho. BMC Public Health 2020; 20:425. [PMID: 32228531 PMCID: PMC7106615 DOI: 10.1186/s12889-020-08535-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 03/16/2020] [Indexed: 01/10/2023] Open
Abstract
Background Despite tremendous progress in controlling the HIV epidemic in sub-Saharan Africa, HIV-related mortality continues to increase among adolescents and young people living with HIV (AYPLHIV). Globally, sub-Saharan Africa accounts for 85% of the AYPLHIV. Overall outcomes along the HIV care cascade are worse among AYPLHIV as compared to all other age groups due to various challenges in accessing and adhering to antiretroviral therapy (ART). New, innovative multicomponent packages of differentiated service delivery (DSD) models, are required to address the specific needs of AYPLHIV. This study aims to evaluate the feasibility and effectiveness of a multicomponent DSD model (PEBRA model) designed for AYPLHIV and coordinated by a peer-educator. Methods PEBRA (Peer-Educator Based Refill of ART) is a cluster randomized, open-label, superiority trial conducted at 20 health facilities in three districts of Lesotho, Southern Africa. The clusters (health facilities) are randomly assigned to either the PEBRA model or standard of care in a 1:1 ratio, stratified by district. AYPLHIV aged 15–24 years old in care and on ART at one of the clusters are eligible. In the PEBRA model, a peer-educator coordinates the antiretroviral therapy (ART) services - such as medication pick-up, SMS notifications and support options - according to the preferences of the AYPLHIV. The peer-educator delivers this personalized model using a tablet-based application called PEBRApp. The control clusters continue to offer standard of care: ART services coordinated by the nurse. The primary endpoint is viral suppression at 12 months. Secondary endpoints include self-reported adherence to ART, quality of life, satisfaction with care and engagement in care. The target sample size is 300 AYPLHIV. Statistical analyses are conducted and reported in line with CONSORT guidelines for cluster randomized trials. Discussion The PEBRA trial will provide evidence on the feasibility and effectiveness of an inclusive, holistic and preference-based DSD model for AYPLHIV that is coordinated by a peer-educator. Many countries in SSA have an existing peer-educator program. If proven effective, the PEBRA model and PEBRApp have the potential to be scaled up to similar settings. Trial registration Clinicaltrials.gov, NCT03969030. Registered on 31 May 2019. More information: www.pebra.info
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Affiliation(s)
| | | | - Nadine Bachmann
- Department of Medicine, Clinical Research Unit, Swiss Tropical and Public Health Institute, Socinstrasse 57, 4051, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Jennifer Anne Brown
- Department of Medicine, Clinical Research Unit, Swiss Tropical and Public Health Institute, Socinstrasse 57, 4051, Basel, Switzerland.,University of Basel, Basel, Switzerland.,Molecular Virology, Department of Biomedicine, University of Basel, Basel, Switzerland
| | - Tracy Renée Glass
- Department of Medicine, Clinical Research Unit, Swiss Tropical and Public Health Institute, Socinstrasse 57, 4051, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | | | | | - Ramona Scherrer
- Department of Medicine, Clinical Research Unit, Swiss Tropical and Public Health Institute, Socinstrasse 57, 4051, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | | | - Tilo Namane
- Motebang Government Hospital, Leribe, Lesotho
| | - Niklaus Daniel Labhardt
- Department of Medicine, Clinical Research Unit, Swiss Tropical and Public Health Institute, Socinstrasse 57, 4051, Basel, Switzerland.,University of Basel, Basel, Switzerland.,Department of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | - Alain Amstutz
- Department of Medicine, Clinical Research Unit, Swiss Tropical and Public Health Institute, Socinstrasse 57, 4051, Basel, Switzerland. .,University of Basel, Basel, Switzerland. .,Department of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland.
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Moudachirou R, Van Cutsem G, Chuy RI, Tweya H, Senkoro M, Mabhala M, Zolfo M. Retention and sustained viral suppression in HIV patients transferred to community refill centres in Kinshasa, DRC. Public Health Action 2020; 10:33-37. [PMID: 32368522 DOI: 10.5588/pha.19.0067] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 12/16/2019] [Indexed: 11/10/2022] Open
Abstract
Setting In 2010, Médecins Sans Frontières set up decentralised community antiretroviral therapy (ART) refill centres ("poste de distribution communautaire", PODI) for the follow-up of stable human immunodeficiency virus (HIV) patients. Objective To assess retention in care and sustained viral suppression after transfer to three main PODI in Kinshasa, Democratic Republic of Congo (DRC) (PODI Barumbu/Central, PODI Binza Ozone/West and PODI Masina I/East). Design Retrospective cohort study using routine programme data for adult HIV patients transferred from Kabinda Hospital to PODIs between January 2015 and June 2017. Results A total of 337 patients were transferred to PODIs: 306 (91%) were on ART for at least 12 months; 118 (39%) had a routine "12-month" viral load (VL) done, 93% (n = 110) of whom had a suppressed VL <1000 copies/ml. Median time from enrolment into PODI to 12-month routine VL was 14.6 months (IQR 12.2-20.8). Kaplan-Meier estimates of retention in care at 6, 12 and 18 months after enrolment into PODIs were respectively 96%, 92% and 88%. Conclusion Retention in care and viral suppression among patients in PODI with VL results were better than patients in clinic care and national outcomes.
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Affiliation(s)
- R Moudachirou
- Projet SIDA, Médecins Sans Frontières, Operational Centre of Brussels, Kinshasa, Democratic Republic of Congo
| | - G Van Cutsem
- Southern Africa Medical Unit, Médecins Sans Frontières, Cape Town, South Africa.,9 Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa
| | - R I Chuy
- Programme National de Lutte contre le VIH/SIDA et les IST, Kinshasa, DRC
| | - H Tweya
- International Union Against Tuberculosis and Lung Disease, Paris, France.,The Lighthouse Trust, Lilongwe, Malawi
| | - M Senkoro
- National Institute for Medical Research, Muhimbili Centre, Dares-Salaam, Tanzania
| | - M Mabhala
- Department of Public Health and Wellbeing, University of Chester, Chester, UK
| | - M Zolfo
- Institute of Tropical Medicine, Antwerp, Belgium
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Eligibility for differentiated models of HIV treatment service delivery: an estimate from Malawi and Zambia. AIDS 2020; 34:475-479. [PMID: 31764076 DOI: 10.1097/qad.0000000000002435] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Little is known about the proportion of HIV-positive clients on antiretroviral therapy (ART) who meet stability criteria for differentiated service delivery (DSD) models. We report the proportion of ART clients meeting stability criteria as part of screening for a randomized trial of multimonth dispensing in Malawi and Zambia. METHODS For a DSD trial now underway, we screened HIV-positive clients aged at least 18 years presenting for HIV treatment in 30 adult ART clinics in Malawi and Zambia to determine eligibility for DSD. Stability was defined as on first-line ART (efavirenz/tenofovir/lamivudine) for at least 6 months, no ART side effects, no toxicity or infectious complications, no noncommunicable diseases being treated in ART clinic, no lapses in ART adherence in the prior 6 months (>30 days without taking ART), and if female, not pregnant or breastfeeding. RESULTS In total, 3465 adult ART clients were approached between 10 May 2017 and 30 April 2018 (Malawi: 1680; Zambia: 1785). Of the 2938 who answered screening questions (Malawi: 1527; Zambia: 1411), 2173 (73.5%) met criteria for DSD eligibility (Malawi: 72.8%; Zambia: 74.3%). The most common reasons for ineligibility were being on ART less than 6 months (9.6%) and a regimen other than standard first-line (7.9%). CONCLUSION Approximately three-quarters of all adult clients presenting at ART clinics in Malawi and Zambia were eligible for DSD using a typical definition of stability. High uptake of DSD models by eligible clients would have a major impact on the infrastructure and the allocation of HIV treatment resources.
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Abstract
PURPOSE OF REVIEW Differentiated service delivery (DSD) has emerged as an approach for HIV programs seeking to better serve the needs of people living with HIV, reduce unnecessary burdens on the health system, and improve client outcomes. We reviewed recent evidence that addresses the challenge of DSD scale-up. RECENT FINDINGS Most current evidence focuses on treatment of clinically stable adult clients in high HIV prevalence settings. Nonetheless, a growing body of research is emerging on how the concept of differentiation is being applied to HIV testing, linkage, and initiation; service delivery to specific demographic groups including key populations - MSM, people who inject drugs, people in prisons, sex workers, and transgender people; service delivery to adolescents and pregnant women; and impact on related medical conditions like advanced HIV. There is also an increasing emphasis on measuring client experience. Key barriers to scale-up include the capacity of monitoring and evaluation systems, access to viral load monitoring and funding for community-led demand generation efforts. Another barrier is the lack of sufficient data to evaluate the various manifestations of the DSD model. SUMMARY Emerging evidence is providing welcome nuance to the discourse on the concept of DSD for HIV. The challenge will be taking evolving DSD concepts from pilot to scale. Countries must review their particular context, define the expected needs of their clients in different settings, introduce appropriate models - and be willing to adjust programming based on quantitative and qualitative outcomes.
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Abstract
Purpose of Review Clinical trials have found that PrEP is highly effective in reducing risk of HIV acquisition across types of exposure, gender, PrEP regimens, and dosing schemes. Evidence is urgently needed to inform scale-up of PrEP to meet the ambitious WHO/UNAIDS prevention target of 3,000,000 individuals on PrEP by 2020. Recent Findings Successful models of delivering HIV services at scale evolved from years of formal research and programmatic evidence. These efforts produced lessons-learned relevant for scaling-up PrEP delivery, including the importance of streamlining laboratory tests, expanding prescription and management authority, differentiating medication access points, and reducing stigma and barriers of parental consent for PrEP uptake. Further research is especially needed in areas differentiating PrEP from ART delivery, including repeat HIV testing to ensure HIV negative status and defining and measuring prevention-effective adherence. Summary Evidence from 15 years of ART scale-up could immediately inform a public health approach to PrEP delivery.
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Okere NE, Urlings L, Naniche D, de Wit TFR, Gomez GB, Hermans S. Evaluating the sustainability of differentiated service delivery interventions for stable ART clients in sub-Saharan Africa: a systematic review protocol. BMJ Open 2020; 10:e033156. [PMID: 32014874 PMCID: PMC7045032 DOI: 10.1136/bmjopen-2019-033156] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 12/18/2019] [Accepted: 12/20/2019] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION In 2015, WHO recommended immediate treatment for people living with HIV (PLHIV). As a result, the number of PLHIV needing antiretroviral therapy (ART) in sub-Saharan Africa (SSA) doubled from 12 million to over 25 million. This put a strain on already weak health systems and inspired the exploration of innovative service delivery models-differentiated service delivery (DSD). In DSD, services are tailored according to client clinical type and offer much-needed improvement in efficiency. The potential of achieving good outcomes for both clients and the health system plus the promise of sustainability motivates DSD promotion especially in low-income and middle-income countries. This review aims to evaluate the sustainability of DSD interventions. METHODS AND ANALYSIS We will systematically review peer-reviewed English literature published between 2000 and 2019 identified by searching PubMed and EMBASE databases. Main inclusion criteria comprise studies describing DSD interventions conducted in SSA focused on stable adult ART clients, whether described alone or compared with clinic-based service delivery. Quality of included studies will be assessed employing the Down and Black's and Joanne Briggs Institute checklists for quantitative and qualitative studies, respectively. We will apply a comprehensive sustainability framework including 40 individual constructs to evaluate, score and rank each intervention for sustainability. Narrative and quantitative synthesis will be conducted as appropriate. ETHICS AND DISSEMINATION No ethical approval is required for this study as it is a review of published or publicly available data. Review results will be published in a peer-reviewed journal and presented at international conferences. PROSPERO REGISTRATION NUMBER CRD42019120891.
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Affiliation(s)
- Nwanneka Ebelechukwu Okere
- Global Health, University of Amsterdam, Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands
| | - Lisa Urlings
- Medicine, Amsterdam University Medical Centres, Amsterdam, Noord-Holland, The Netherlands
| | - Denise Naniche
- Global Health, University of Barcelona, Barcelona Institute for Global Health, Barcelona, Catalunya, Spain
| | - Tobias F Rinke de Wit
- Global Health, University of Amsterdam, Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands
| | - Gabriela B Gomez
- Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Sabine Hermans
- Global Health, University of Amsterdam, Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands
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