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Beres LK, Underwood A, Le Tourneau N, Kemp CG, Kore G, Yaeger L, Li J, Aaron A, Keene C, Mallela DP, Khalifa BAA, Mody A, Schwartz SR, Baral S, Mwamba C, Sikombe K, Eshun-Wilson I, Geng EH, Lavoie MCC. Person-centred interventions to improve patient-provider relationships for HIV services in low- and middle-income countries: a systematic review. J Int AIDS Soc 2024; 27:e26258. [PMID: 38740547 DOI: 10.1002/jia2.26258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 04/16/2024] [Indexed: 05/16/2024] Open
Abstract
INTRODUCTION Person-centred care (PCC) has been recognized as a critical element in delivering quality and responsive health services. The patient-provider relationship, conceptualized at the core of PCC in multiple models, remains largely unexamined in HIV care. We conducted a systematic review to better understand the types of PCC interventions implemented to improve patient-provider interactions and how these interventions have improved HIV care continuum outcomes and person-reported outcomes (PROs) among people living with HIV in low- and middle-income countries. METHODS We searched databases, conference proceedings and conducted manual targeted searches to identify randomized trials and observational studies published up to January 2023. The PCC search terms were guided by the Integrative Model of Patient-Centeredness by Scholl. We included person-centred interventions aiming to enhance the patient-provider interactions. We included HIV care continuum outcomes and PROs. RESULTS We included 28 unique studies: 18 (64.3%) were quantitative, eight (28.6.%) were mixed methods and two (7.1%) were qualitative. Within PCC patient-provider interventions, we inductively identified five categories of PCC interventions: (1) providing friendly and welcoming services; (2) patient empowerment and improved communication skills (e.g. supporting patient-led skills such as health literacy and approaches when communicating with a provider); (3) improved individualized counselling and patient-centred communication (e.g. supporting provider skills such as training on motivational interviewing); (4) audit and feedback; and (5) provider sensitisation to patient experiences and identities. Among the included studies with a comparison arm and effect size reported, 62.5% reported a significant positive effect of the intervention on at least one HIV care continuum outcome, and 100% reported a positive effect of the intervention on at least one of the included PROs. DISCUSSION Among published HIV PCC interventions, there is heterogeneity in the components of PCC addressed, the actors involved and the expected outcomes. While results are also heterogeneous across clinical and PROs, there is more evidence for significant improvement in PROs. Further research is necessary to better understand the clinical implications of PCC, with fewer studies measuring linkage or long-term retention or viral suppression. CONCLUSIONS Improved understanding of PCC domains, mechanisms and consistency of measurement will advance PCC research and implementation.
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Affiliation(s)
- Laura K Beres
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
| | - Ashley Underwood
- Washington University in St. Louis School of Medicine, St Louis, Missouri, USA
| | - Noelle Le Tourneau
- Washington University in St. Louis School of Medicine, St Louis, Missouri, USA
| | | | - Gauri Kore
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Lauren Yaeger
- Washington University in St. Louis School of Medicine, St Louis, Missouri, USA
| | - Jingjia Li
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Alec Aaron
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | | | - Banda A A Khalifa
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Aaloke Mody
- Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
| | | | - Stefan Baral
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Chanda Mwamba
- Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
| | - Kombatende Sikombe
- Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
| | - Ingrid Eshun-Wilson
- Washington University in St. Louis School of Medicine, St Louis, Missouri, USA
| | - Elvin H Geng
- Washington University in St. Louis School of Medicine, St Louis, Missouri, USA
| | - Marie-Claude C Lavoie
- Center for International Health Education and Biosecurity, University of Maryland School of Medicine, Baltimore, Maryland, USA
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, Maryland, USA
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Irie WC, Kerkhoff A, Kim HY, Geng E, Eshun-Wilson I. Using stated preference methods to facilitate knowledge translation in implementation science. Implement Sci Commun 2024; 5:32. [PMID: 38549129 PMCID: PMC10979589 DOI: 10.1186/s43058-024-00554-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 02/01/2024] [Indexed: 04/01/2024] Open
Abstract
Enhancing the arsenal of methods available to shape implementation strategies and bolster knowledge translation is imperative. Stated preference methods, including discrete choice experiments (DCE) and best-worst scaling (BWS), rooted in economics, emerge as robust, theory-driven tools for understanding and influencing the behaviors of both recipients and providers of innovation. This commentary outlines the wide-ranging application of stated preference methods across the implementation continuum, ushering in effective knowledge translation. The prospects for utilizing these methods within implementation science encompass (1) refining and tailoring intervention and implementation strategies, (2) exploring the relative importance of implementation determinants, (3) identifying critical outcomes for key decision-makers, and 4) informing policy prioritization. Operationalizing findings from stated preference research holds the potential to precisely align health products and services with the requisites of patients, providers, communities, and policymakers, thereby realizing equitable impact.
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Affiliation(s)
- Whitney C Irie
- School of Social Work, Boston College, Chestnut Hill, MA, USA.
| | - Andrew Kerkhoff
- Division of HIV, Infectious Diseases and Global Medicine Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, San Francisco, CA, USA
| | - Hae-Young Kim
- Department of Population Health at NYU Grossman School of Medicine, New York, NY, USA
| | - Elvin Geng
- Division of Infectious Diseases, School of Medicine, Washington University in Saint Louis, Saint Louis, MO, USA
| | - Ingrid Eshun-Wilson
- Division of Infectious Diseases, School of Medicine, Washington University in Saint Louis, Saint Louis, MO, USA
- Department of Global Health, Stellenbosch University, Cape Town, South Africa
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Akama EO, Beres LK, Kulzer JL, Ontuga G, Adhiambo H, Bushuru S, Nyagesoa E, Osoro J, Opondo I, Sang N, Oketch B, Nyanga J, Osongo CO, Nyandieka E, Ododa E, Omondi E, Ochieng F, Owino C, Odeny T, Kwena ZA, Eshun-Wilson I, Petersen M, Bukusi EA, Geng EH, Abuogi LL. A youth-centred approach to improving engagement in HIV services: human-centred design methods and outcomes in a research trial in Kisumu County, Kenya. BMJ Glob Health 2023; 8:e012606. [PMID: 38030226 PMCID: PMC10689376 DOI: 10.1136/bmjgh-2023-012606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 10/01/2023] [Indexed: 12/01/2023] Open
Abstract
IntroductionInnovative interventions are needed to improve HIV outcomes among adolescents and young adults (AYAs) living with HIV. Engaging AYAs in intervention development could increase effectiveness and youth acceptance, yet research is limited. We applied human-centred design (HCD) to refine adherence-support interventions pretrial and assessed HCD workshop acceptability. METHODS We applied an iterative, four-phased HCD process in Kenya that included: (1) systematic review of extant knowledge, (2) prioritisation of design challenges, (3) a co-creation workshop and (4) translation tables to pair insights with trial intervention adaptations. The co-creation workshop was co-led by youth facilitators employing participatory activities to inform intervention adaptations. Iterative data analysis included rapid thematic analysis of visualised workshop outputs and notes using affinity mapping and dialogue to identify key themes. We conducted a survey to assess workshop acceptability among participants. RESULTS Twenty-two participants engaged in the 4-day workshop. Co-creation activities yielded recommendations for improving planned interventions (eg, message frequency and content; strategies to engage hard-to-reach participants), critical principles to employ across interventions (eg, personalisation, AYA empowerment) and identification of unanticipated AYA HIV treatment priorities (eg, drug holidays, transition from adolescent to adult services). We revised intervention content, peer navigator training materials and study inclusion criteria in response to findings. The youth-led HCD workshop was highly acceptable to participants. CONCLUSIONS Research employing HCD among youth can improve interventions preimplementation through empathy, youth-led inquiry and real-time problem solving. Peer navigation may be most influential in improving retention when engagement with young people is based on mutual trust, respect, privacy and extends beyond HIV-specific support. Identifying opportunities for personalisation and adaptation within intervention delivery is important for AYAs. Patient engagement interventions that target young people should prioritise improved transition between youth and adult services, youth HIV status disclosure, AYA empowerment and healthcare worker responsiveness in interactions and episodic adherence interruptions.
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Affiliation(s)
- Eliud Omondi Akama
- Centre for Microbiology Research (CMR), Kenya Medical Research Institute, Nairobi, Kenya
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Laura K Beres
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Jayne Lewis Kulzer
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, California, USA
| | - Gladys Ontuga
- Centre for Microbiology Research (CMR), Kenya Medical Research Institute, Nairobi, Kenya
| | - Harriet Adhiambo
- Centre for Microbiology Research (CMR), Kenya Medical Research Institute, Nairobi, Kenya
- Department of Child, Family, and Population Health Nursing, University of Washington, Seattle, Washington, USA
| | - Sarah Bushuru
- Centre for Microbiology Research (CMR), Kenya Medical Research Institute, Nairobi, Kenya
| | - Edwin Nyagesoa
- Centre for Microbiology Research (CMR), Kenya Medical Research Institute, Nairobi, Kenya
| | - Joseph Osoro
- Centre for Microbiology Research (CMR), Kenya Medical Research Institute, Nairobi, Kenya
| | - Isaya Opondo
- Centre for Microbiology Research (CMR), Kenya Medical Research Institute, Nairobi, Kenya
| | - Norton Sang
- Centre for Microbiology Research (CMR), Kenya Medical Research Institute, Nairobi, Kenya
| | - Bertha Oketch
- Centre for Microbiology Research (CMR), Kenya Medical Research Institute, Nairobi, Kenya
| | - James Nyanga
- Centre for Microbiology Research (CMR), Kenya Medical Research Institute, Nairobi, Kenya
| | - Cirilus Ogollah Osongo
- Centre for Microbiology Research (CMR), Kenya Medical Research Institute, Nairobi, Kenya
- Family AIDS Care and Education Services (FACES) Clinic, Kisumu, Kenya
| | - Evelyn Nyandieka
- Centre for Microbiology Research (CMR), Kenya Medical Research Institute, Nairobi, Kenya
| | - Evelyn Ododa
- Centre for Microbiology Research (CMR), Kenya Medical Research Institute, Nairobi, Kenya
| | - Eunice Omondi
- Centre for Microbiology Research (CMR), Kenya Medical Research Institute, Nairobi, Kenya
| | - Felix Ochieng
- Centre for Microbiology Research (CMR), Kenya Medical Research Institute, Nairobi, Kenya
| | - Clinton Owino
- Centre for Microbiology Research (CMR), Kenya Medical Research Institute, Nairobi, Kenya
| | - Thomas Odeny
- Centre for Microbiology Research (CMR), Kenya Medical Research Institute, Nairobi, Kenya
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Zachary Arochi Kwena
- Centre for Microbiology Research (CMR), Kenya Medical Research Institute, Nairobi, Kenya
| | - Ingrid Eshun-Wilson
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Maya Petersen
- Biostatistics and Epidemiology, University of California, Berkeley, California, USA
| | - Elizabeth A Bukusi
- Centre for Microbiology Research (CMR), Kenya Medical Research Institute, Nairobi, Kenya
| | - Elvin H Geng
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Lisa L Abuogi
- Department of Pediatrics, University of Colorado, Denver, Colorado, USA
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Kitenge MK, Fatti G, Eshun-Wilson I, Aluko O, Nyasulu P. Prevalence and trends of advanced HIV disease among antiretroviral therapy-naïve and antiretroviral therapy-experienced patients in South Africa between 2010-2021: a systematic review and meta-analysis. BMC Infect Dis 2023; 23:549. [PMID: 37608300 PMCID: PMC10464046 DOI: 10.1186/s12879-023-08521-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 08/08/2023] [Indexed: 08/24/2023] Open
Abstract
BACKGROUND Despite the significant progress made in South Africa in getting millions of individuals living with HIV into care, many patients still present or re-enter care with Advanced HIV Disease (AHD). We aimed to estimate the prevalence of AHD among ART-naive and ART-experienced patients in South Africa using studies published between January 2010 and May 2022. METHODS We searched for relevant data on PubMed, CINAHL, Scopus and other sources, with a geographical filters limited to South Africa, up to May 31, 2022. Two reviewers conducted all screening, eligibility assessment, data extraction, and critical appraisal. We synthesized the data using the inverse-variance heterogeneity model and Freeman-Tukey transformation. We assessed heterogeneity using the I2 statistic and publication bias using the Egger and Begg's test. RESULTS We identified 2,496 records, of which 53 met the eligibility criteria, involving 11,545,460 individuals. The pooled prevalence of AHD among ART-naive and ART-experienced patients was 43.45% (95% CI 40.1-46.8%, n = 53 studies) and 58.6% (95% CI 55.7 to 61.5%, n = 2) respectively. The time trend analysis showed a decline of 2% in the prevalence of AHD among ART-naive patients per year. However, given the high heterogeneity between studies, the pooled prevalence should be interpreted with caution. CONCLUSION Despite HIV's evolution to a chronic disease, our findings show that the burden of AHD remains high among both ART-naive and ART-experienced patients in South Africa. This emphasizes the importance of regular measurement of CD4 cell count as an essential component of HIV care. In addition, providing innovative adherence support and interventions to retain ART patients in effective care is a crucial priority for those on ART.
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Affiliation(s)
- Marcel K Kitenge
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.
- Tuberculosis and HIV investigative Network (THINK), Durban, Kwazulu-Natal, South Africa.
| | - Geoffrey Fatti
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Kheth'Impilo AIDS Free Living, Cape Town, South Africa
| | - Ingrid Eshun-Wilson
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Division of Infectious Diseases, School of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Omololu Aluko
- Faculty of Health Sciences, School of Medical Sciences, Department of Biostatistics, University of the Free State, Bloemfontein, South Africa
| | - Peter Nyasulu
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Division of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Sikombe K, Pry JM, Mody A, Rice B, Bukankala C, Eshun-Wilson I, Mutale J, Simbeza S, Beres LK, Mukamba N, Mukumbwa-Mwenechanya M, Mwamba D, Sharma A, Wringe A, Hargreaves J, Bolton-Moore C, Holmes C, Sikazwe IT, Geng E. Comparison of patient exit interviews with unannounced standardised patients for assessing HIV service delivery in Zambia: a study nested within a cluster randomised trial. BMJ Open 2023; 13:e069086. [PMID: 37407057 DOI: 10.1136/bmjopen-2022-069086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/07/2023] Open
Abstract
OBJECTIVES To compare unannounced standardised patient approach (eg, mystery clients) with typical exit interviews for assessing patient experiences in HIV care (eg, unfriendly providers, long waiting times). We hypothesise standardised patients would report more negative experiences than typical exit interviews affected by social desirability bias. SETTING Cross-sectional surveys in 16 government-operated HIV primary care clinics in Lusaka, Zambia providing antiretroviral therapy (ART). PARTICIPANTS 3526 participants aged ≥18 years receiving ART participated in the exit surveys between August 2019 and November 2021. INTERVENTION Systematic sample (every nth file) of patients in clinic waiting area willing to be trained received pre-visit training and post-visit interviews. Providers were unaware of trained patients. OUTCOME MEASURES We compared patient experience among patients who received brief training prior to their care visit (explaining each patient experience construct in the exit survey, being anonymous, without manipulating behaviour) with those who did not undergo training on the survey prior to their visit. RESULTS Among 3526 participants who participated in exit surveys, 2415 were untrained (56% female, median age 40 (IQR: 32-47)) and 1111 were trained (50% female, median age 37 (IQR: 31-45)). Compared with untrained, trained patients were more likely to report a negative care experience overall (adjusted prevalence ratio (aPR) for aggregate sum score: 1.64 (95% CI: 1.39 to 1.94)), with a greater proportion reporting feeling unwelcome by providers (aPR: 1.71 (95% CI: 1.20 to 2.44)) and witnessing providers behaving rude (aPR: 2.28 (95% CI: 1.63 to 3.19)). CONCLUSION Trained patients were more likely to identify suboptimal care. They may have understood the items solicited better or felt empowered to be more critical. We trained existing patients, unlike studies that use 'standardised patients' drawn from outside the patient population. This low-cost strategy could improve patient-centred service delivery elsewhere. TRIAL REGISTRATION NUMBER Assessment was nested within a parent study; www.pactr.org registered the parent study (PACTR202101847907585).
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Affiliation(s)
- Kombatende Sikombe
- Implementation Science Unit, Center for Infectious Disease Research in Zambia, Lusaka, Zambia
- Department of Public Health, Environments and Society, London School of Hygiene and Tropical Medicine Faculty of Public Health and Policy, London, UK
| | - Jake M Pry
- Implementation Science Unit, Center for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Aaloke Mody
- Internal Medicine, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - Brian Rice
- Department of Public Health, Environments and Society, London School of Hygiene and Tropical Medicine Faculty of Public Health and Policy, London, UK
| | - Chama Bukankala
- Implementation Science Unit, Center for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Ingrid Eshun-Wilson
- Internal Medicine, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - Jacob Mutale
- Implementation Science Unit, Center for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Sandra Simbeza
- Implementation Science Unit, Center for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Laura K Beres
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Njekwa Mukamba
- Social and Behavioural Science Research Group, Center for Infectious Disease Research in Zambia, Lusaka, Zambia
| | | | - Daniel Mwamba
- Implementation Science Unit, Center for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Anjali Sharma
- Social and Behavioural Science Research Group, Center for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Alison Wringe
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - James Hargreaves
- Department of Public Health, Environments and Society, London School of Hygiene and Tropical Medicine Faculty of Public Health and Policy, London, UK
| | - Carolyn Bolton-Moore
- Implementation Science Unit, Center for Infectious Disease Research in Zambia, Lusaka, Zambia
- Department of Medicine, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Charles Holmes
- Center for Innovation in Global Health, Georgetown University Medical Center, Washington, District of Columbia, USA
| | - Izukanji T Sikazwe
- Implementation Science Unit, Center for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Elvin Geng
- Internal Medicine, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
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Kilbourne AM, Geng E, Eshun-Wilson I, Sweeney S, Shelley D, Cohen DJ, Kirchner JE, Fernandez ME, Parchman ML. How does facilitation in healthcare work? Using mechanism mapping to illuminate the black box of a meta-implementation strategy. Implement Sci Commun 2023; 4:53. [PMID: 37194084 DOI: 10.1186/s43058-023-00435-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 05/06/2023] [Indexed: 05/18/2023] Open
Abstract
BACKGROUND Healthcare facilitation, an implementation strategy designed to improve the uptake of effective clinical innovations in routine practice, has produced promising yet mixed results in randomized implementation trials and has not been fully researched across different contexts. OBJECTIVE Using mechanism mapping, which applies directed acyclic graphs that decompose an effect of interest into hypothesized causal steps and mechanisms, we propose a more concrete description of how healthcare facilitation works to inform its further study as a meta-implementation strategy. METHODS Using a modified Delphi consensus process, co-authors developed the mechanistic map based on a three-step process. First, they developed an initial logic model by collectively reviewing the literature and identifying the most relevant studies of healthcare facilitation components and mechanisms to date. Second, they applied the logic model to write vignettes describing how facilitation worked (or did not) based on recent empirical trials that were selected via consensus for inclusion and diversity in contextual settings (US, international sites). Finally, the mechanistic map was created based on the collective findings from the vignettes. FINDINGS Theory-based healthcare facilitation components informing the mechanistic map included staff engagement, role clarification, coalition-building through peer experiences and identifying champions, capacity-building through problem solving barriers, and organizational ownership of the implementation process. Across the vignettes, engagement of leaders and practitioners led to increased socialization of the facilitator's role in the organization. This in turn led to clarifying of roles and responsibilities among practitioners and identifying peer experiences led to increased coherence and sense-making of the value of adopting effective innovations. Increased trust develops across leadership and practitioners through expanded capacity in adoption of the effective innovation by identifying opportunities that mitigated barriers to practice change. Finally, these mechanisms led to eventual normalization and ownership of the effective innovation and healthcare facilitation process. IMPACT Mapping methodology provides a novel perspective of mechanisms of healthcare facilitation, notably how sensemaking, trust, and normalization contribute to quality improvement. This method may also enable more efficient and impactful hypothesis-testing and application of complex implementation strategies, with high relevance for lower-resourced settings, to inform effective innovation uptake.
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Affiliation(s)
- Amy M Kilbourne
- Health Services Research & Development, VA Office of Research and Development, US Department of Veterans Affairs and University of Michigan, 810 Vermont Ave, NW, Washington, D.C., 20420, USA.
| | - Elvin Geng
- Washington University at St. Louis, St. Louis, MO, USA
| | | | | | - Donna Shelley
- New York University School of Global Public Health, New York, New York, USA
| | | | - JoAnn E Kirchner
- Central Arkansas VA Healthcare System and University of Arkansas for Medical Sciences, North Little Rock, AR, USA
| | - Maria E Fernandez
- University of Texas Health Science Center at Houston, School of Public Health, Houston, TX, USA
| | - Michael L Parchman
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
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7
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Abuogi LL, Kulzer JL, Akama E, Odeny TA, Eshun-Wilson I, Petersen M, Shade SB, Montoya LM, Beres LK, Iguna S, Adhiambo HF, Osoro J, Opondo I, Sang N, Kwena Z, Bukusi EA, Geng EH. Adapt for Adolescents: Protocol for a sequential multiple assignment randomized trial to improve retention and viral suppression among adolescents and young adults living with HIV in Kenya. Contemp Clin Trials 2023; 127:107123. [PMID: 36813086 PMCID: PMC10075086 DOI: 10.1016/j.cct.2023.107123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 02/15/2023] [Accepted: 02/16/2023] [Indexed: 02/22/2023]
Abstract
BACKGROUND Adolescents and young adults living with HIV (AYAH) aged 14-24 years in Africa experience substantially higher rates of virological failure and HIV-related mortality than adults. We propose to utilize developmentally appropriate interventions with high potential for effectiveness, tailored by AYAH pre-implementation, in a sequential multiple assignment randomized trial (SMART) aimed at improving viral suppression for AYAH in Kenya. METHODS Using a SMART design, we will randomize 880 AYAH in Kisumu, Kenya to either youth-centered education and counseling (standard of care) or electronic peer navigation in which a peer provides support, information, and counseling via phone and automated monthly text messages. Those with a lapse in engagement (defined as either a missed clinic visit by ≥14 days or HIV viral load ≥1000 copies/ml) will be randomized a second time to one of three higher-intensity re-engagement interventions: This study will evaluate which interventions and which dynamic sequence of interventions improve sustained viral suppression and HIV care engagement in AYAH at 24 months post-enrollment and assess the cost-effectiveness of successful strategies. DISCUSSION The study utilizes promising interventions tailored to AYAH while optimizing resources by intensifying services only for those AYAH who need more support. Findings from this innovative study will offer evidence for public health programming to end the HIV epidemic as a public health threat for AYAH in Africa. TRIAL REGISTRATION Clinicaltrials.govNCT04432571, registered June 16, 2020.
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Affiliation(s)
- Lisa L Abuogi
- Department of Pediatrics, University of Colorado, Denver, Aurora, CO, USA.
| | - Jayne Lewis Kulzer
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, CA, USA
| | - Eliud Akama
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Thomas A Odeny
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya; School of Medicine, Washington University, St. Louis, MO, USA
| | | | - Maya Petersen
- Division of Biostatistics, School of Public Health, University of California, Berkeley, CA, USA
| | - Starley B Shade
- Department of Epidemiology and Biostatistics, Institute for Global Health Sciences, University of California, San Francisco, CA, USA
| | - Lina M Montoya
- Department of Biostatistics, University of North Carolina at Chapel Hill, NC, USA
| | - Laura K Beres
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Sarah Iguna
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Harriet F Adhiambo
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Joseph Osoro
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Isaya Opondo
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Norton Sang
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Zachary Kwena
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Elizabeth A Bukusi
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Elvin H Geng
- School of Medicine, Washington University, St. Louis, MO, USA
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8
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Geng EH, Odeny TA, Montoya LM, Iguna S, Kulzer JL, Adhiambo HF, Eshun-Wilson I, Akama E, Nyandieka E, Guzé MA, Shade S, Packel L, Fox B, Camlin C, Thirumurthy H, Lyons C, Bukusi EA, Petersen ML. Adaptive Strategies for Retention in Care among Persons Living with HIV. NEJM Evid 2023; 2:10.1056/evidoa2200076. [PMID: 38143482 PMCID: PMC10745095 DOI: 10.1056/evidoa2200076] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2023]
Abstract
BACKGROUND Optimizing retention in human immunodeficiency virus (HIV) treatment may require sequential behavioral interventions based on patients' response. METHODS In a sequential multiple assignment randomized trial in Kenya, we randomly assigned adults initiating HIV treatment to standard of care (SOC), Short Message Service (SMS) messages, or conditional cash transfers (CCT). Those with retention lapse (missed a clinic visit by ≥14 days) were randomly assigned again to standard-of-care outreach (SOC-Outreach), SMS+CCT, or peer navigation. Those randomly assigned to SMS or CCT who did not lapse after 1 year were randomly assigned again to either stop or continue the initial intervention. Primary outcomes were retention in care without an initial lapse, return to the clinic among those who lapsed, and time in care; secondary outcomes included adjudicated viral suppression. Average treatment effect (ATE) was calculated using targeted maximum likelihood estimation with adjustment for baseline characteristics at randomization and certain time-varying characteristics at rerandomization. RESULTS Among 1809 participants, 79.7% of those randomly assigned to CCT (n=523/656), 71.7% to SMS (n=393/548), and 70.7% to SOC (n=428/605) were retained in care in the first year (ATE: 9.9%; 95% confidence interval [CI]: 5.4%, 14.4% and ATE: 4.2%; 95% CI: -0.7%, 9.2% for CCT and SMS compared with SOC, respectively). Among 312 participants with an initial lapse who were randomly assigned again, 69.1% who were randomly assigned to a navigator (n=76/110) returned, 69.5% randomly assigned to CCT+SMS (n=73/105) returned, and 55.7% randomly assigned to SOC-Outreach (n=54/97) returned (ATE: 14.1%; 95% CI: 0.6%, 27.6% and ATE: 11.4%; 95% CI: -2.2%, 24.9% for navigator and CCT+SMS compared with SOC-Outreach, respectively). Among participants without lapse on SMS, continuing SMS did not affect retention (n=122/180; 67.8% retained) versus stopping (n=151/209; 72.2% retained; ATE: -4.4%; 95% CI: -16.6%, 7.9%). Among participants without lapse on CCT, those continuing CCT had higher retention (n=192/230; 83.5% retained) than those stopping (n=173/287; 60.3% retained; ATE: 28.6%; 95% CI: 19.9%, 37.3%). Among 15 sequenced strategies, initial CCT, escalated to navigator if lapse occurred and continued if no lapse occurred, increased time in care (ATE: 7.2%, 95% CI: 3.7%, 10.7%) and viral suppression (ATE: 8.2%, 95% CI: 2.2%, 14.2%), the most compared with SOC throughout. Initial SMS escalated to navigator if lapse occurred, and otherwise continued, showed similar effect sizes compared with SOC throughout. CONCLUSIONS Active interventions to prevent retention lapses followed by navigation for those who lapse and maintenance of initial intervention for those without lapse resulted in best overall retention and viral suppression among the strategies studied. Among those who remained in care, discontinuation of CCT, but not SMS, compromised retention and suppression. (Funded by National Institutes of Health grants R01 MH104123, K24 AI134413, and R01 AI074345; ClinicalTrials.gov number, NCT02338739.).
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Affiliation(s)
- Elvin H Geng
- Division of Infectious Diseases, Department of Medicine, Washington University in St. Louis, St. Louis
| | - Thomas A Odeny
- Research Care Training Program, Centre for Microbiology Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Lina M Montoya
- Department of Biostatistics, Gillings School of Public Health, University of North Carolina, Chapel Hill
| | - Sarah Iguna
- Research Care Training Program, Centre for Microbiology Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Jayne L Kulzer
- Department of Obstetrics, Gynecology, and Reproductive Services, University of California, San Francisco, San Francisco
| | - Harriet Fridah Adhiambo
- Research Care Training Program, Centre for Microbiology Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Ingrid Eshun-Wilson
- Division of Infectious Diseases, Department of Medicine, Washington University in St. Louis, St. Louis
| | - Eliud Akama
- Research Care Training Program, Centre for Microbiology Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Everlyne Nyandieka
- Research Care Training Program, Centre for Microbiology Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Mary A Guzé
- Division of Prevention Science, Department of Epidemiology and Biostatistics, School of Medicine, University of California, San Francisco, San Francisco
| | - Starley Shade
- Division of Prevention Science, Department of Epidemiology and Biostatistics, School of Medicine, University of California, San Francisco, San Francisco
| | - Laura Packel
- Department of Biostatistics, Gillings School of Public Health, University of North Carolina, Chapel Hill
| | - Branson Fox
- Division of Infectious Diseases, Department of Medicine, Washington University in St. Louis, St. Louis
| | - Carol Camlin
- Department of Obstetrics, Gynecology, and Reproductive Services, University of California, San Francisco, San Francisco
| | - Harsha Thirumurthy
- Division of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia
| | - Catherine Lyons
- Division of HIV, Infectious Diseases and Global Medicine, Department of Medicine, University of California, San Francisco, San Francisco
| | - Elizabeth A Bukusi
- Research Care Training Program, Centre for Microbiology Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Maya L Petersen
- Division of Biostatistics, School of Public Health, University of California, Berkeley, Berkeley
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9
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Eshun-Wilson I, Ford N, Mody A, Beres L, Schwartz S, Baral S, Geng EH. Strengthening implementation guidelines for HIV service delivery: Considerations for future evidence generation and synthesis. PLoS Med 2023; 20:e1004168. [PMID: 36877738 PMCID: PMC10027212 DOI: 10.1371/journal.pmed.1004168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Revised: 03/20/2023] [Indexed: 03/07/2023] Open
Abstract
Ingrid Eshun-Wilson and colleagues summarize gaps in primary HIV implementation research methods and reporting, and propose areas for future methodological development.
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Affiliation(s)
- Ingrid Eshun-Wilson
- Division of Infectious Diseases, School of Medicine, Washington University in Saint Louis, Saint Louis, Missouri, United States of America
- Department of Global Health, Stellenbosch University, Cape Town, South Africa
| | - Nathan Ford
- Department of HIV, Viral Hepatitis and Sexually Transmitted Infectionss, World Health Organization, Geneva, Switzerland
| | - Aaloke Mody
- Division of Infectious Diseases, School of Medicine, Washington University in Saint Louis, Saint Louis, Missouri, United States of America
| | - Laura Beres
- Department of International Health, John Hopkins School of Public Health, Baltimore, Maryland, United States of America
| | - Sheree Schwartz
- Department of Epidemiology, John Hopkins School of Public Health, Baltimore, Maryland, United States of America
| | - Stefan Baral
- Department of Epidemiology, John Hopkins School of Public Health, Baltimore, Maryland, United States of America
| | - Elvin H Geng
- Division of Infectious Diseases, School of Medicine, Washington University in Saint Louis, Saint Louis, Missouri, United States of America
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Eshun-Wilson I, Ford N, Le Tourneau N, Baral S, Schwartz S, Kemp C, Geng E. A Living Database of HIV Implementation Research (LIVE Project): Protocol for Rapid Living Reviews. JMIR Res Protoc 2022; 11:e37070. [PMID: 36197704 PMCID: PMC9582919 DOI: 10.2196/37070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Revised: 07/25/2022] [Accepted: 08/04/2022] [Indexed: 11/13/2022] Open
Abstract
Background HIV implementation research evolves rapidly and is often complex and poorly characterized, which makes the synthesis of data on HIV implementation strategies inherently difficult. This is further compromised by prolonged data abstraction processes due to variable interventions, outcomes, and context, and delays in the publication of review findings; this can all result in outdated and irrelevant systematic reviews. Objective The LIVE project (A Living Database of HIV Implementation Research) aims to overcome these challenges by applying an implementation science lens to the conduct of rapid living systematic reviews and meta-analyses to inform HIV service delivery priorities and guideline development. Methods The LIVE project will generate a series of living systematic reviews exploring implementation strategies for improving HIV cascade outcomes (HIV infection, HIV diagnosis, linkage and retention in HIV care, viral suppression, and mortality). We will search Embase and MEDLINE as well databases specific to review questions for studies conducted after 2004 using predefined search terms to identify studies conducted in any age group or setting, and using implementation strategies that target policy makers, society, health organizations, health workers, and beneficiaries of care and their families. Both randomized controlled trials and observational studies will be included to ensure reviews include pragmatic data. In addition to assessments of methodological quality, features of the implementation strategies, relevance for implementation, and evidence quality will be determined using recognized frameworks. After initial publication, knowledge gaps will be identified, and review questions and search strategies revised to address ongoing critical areas of inquiry. Updated searches will be conducted every 6 months, with subsequent ongoing screening, data abstraction, and revision of meta-analyses. Results As of July 2022, five reviews are at various stages of development within the LIVE project. Three systematic reviews are underway and living review processes are in development for two reviews with estimated completion over the next 12 months. Conclusions This project and resulting systematic reviews will provide critical insights for HIV service delivery to inform international guideline development. International Registered Report Identifier (IRRID) DERR1-10.2196/37070
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Affiliation(s)
- Ingrid Eshun-Wilson
- Division of Infectious Diseases, School of Medicine, Washington University in St. Louis, St. Louis, MO, United States
| | - Nathan Ford
- Department of Global HIV, Hepatitis and Sexually Transmitted Infections Programmes, World Health Organization, Geneva, Switzerland
| | - Noelle Le Tourneau
- Division of Infectious Diseases, School of Medicine, Washington University in St. Louis, St. Louis, MO, United States
| | - Stefan Baral
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, United States
| | - Sheree Schwartz
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, United States
| | - Christopher Kemp
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, United States
| | - Elvin Geng
- Division of Infectious Diseases, School of Medicine, Washington University in St. Louis, St. Louis, MO, United States
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11
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Bolton Moore C, Pry JM, Mukumbwa-Mwenechanya M, Eshun-Wilson I, Topp S, Mwamba C, Roy M, Sohn H, Dowdy DW, Padian N, Holmes CB, Geng EH, Sikazwe I. A controlled study to assess the effects of a Fast Track (FT) service delivery model among stable HIV patients in Lusaka Zambia. PLOS Glob Public Health 2022; 2:e0000108. [PMID: 36962510 PMCID: PMC10021658 DOI: 10.1371/journal.pgph.0000108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 07/08/2022] [Indexed: 06/18/2023]
Abstract
Fast Track models-in which patients coming to facility to pick up medications minimize waiting times through foregoing clinical review and collecting pre-packaged medications-present a potential strategy to reduce the burden of treatment. We examine effects of a Fast Track model (FT) in a real-world clinical HIV treatment program on retention to care comparing two clinics initiating FT care to five similar (in size and health care level), standard of care clinics in Zambia. Within each clinic, we selected a systematic sample of patients meeting FT eligibility to follow prospectively for retention using both electronic medical records as well as targeted chart review. We used a variety of methods including Kaplan Meier (KM) stratified by FT, to compare time to first late pick up, exploring late thresholds at >7, >14 and >28 days, Cox proportional hazards to describe associations between FT and late pick up, and linear mixed effects regression to assess the association of FT with medication possession ratio. A total of 905 participants were enrolled with a median age of 40 years (interquartile range [IQR]: 34-46 years), 67.1% were female, median CD4 count was 499 cells/mm3 (IQR: 354-691), and median time on ART was 5 years (IQR: 3-7). During the one-year follow-up period FT participants had a significantly reduced cumulative incidence of being >7 days late for ART pick-up (0.36, 95% confidence interval [CI]: 0.31-0.41) compared to control participants (0.66; 95% CI: 0.57-0.65). This trend held for >28 days late for ART pick-up appointments, at 23% (95% CI: 18%-28%) among intervention participants and 54% (95% CI: 47%-61%) among control participants. FT models significantly improved timely ART pick up among study participants. The apparent synergistic relationship between refill time and other elements of the FT suggest that FT may enhance the effects of extending visit spacing/multi-month scripting alone. ClinicalTrials.gov Identifier: NCT02776254 https://clinicaltrials.gov/ct2/show/NCT02776254.
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Affiliation(s)
- Carolyn Bolton Moore
- Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
- University of Alabama, School of Medicine, Birmingham, Alabama, United States of America
| | - Jake M. Pry
- Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
- University of California, School of Medicine, Davis, California, United States of America
| | | | - Ingrid Eshun-Wilson
- Washington University, School of Medicine, St Louis, Missouri, United States of America
| | - Stephanie Topp
- James Cook University, College of Public Health, Medical and Vet Sciences, Queensland, Australia
| | - Chanda Mwamba
- Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
| | - Monika Roy
- University of California, School of Medicine, San Francisco, California, United States of America
| | - Hojoon Sohn
- Johns Hopkins University, School of Medicine, Baltimore, Maryland, United States of America
| | - David W. Dowdy
- University of California, School of Public Health, Berkeley, California, United States of America
| | - Nancy Padian
- University of California, School of Public Health, Berkeley, California, United States of America
| | - Charles B. Holmes
- Georgetown University, School of Medicine, Washington, DC, United States of America
| | - Elvin H. Geng
- James Cook University, College of Public Health, Medical and Vet Sciences, Queensland, Australia
| | - Izukanji Sikazwe
- Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
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12
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Mody A, Bradley C, Redkar S, Fox B, Eshun-Wilson I, Hlatshwayo MG, Trolard A, Tram KH, Filiatreau LM, Thomas F, Haslam M, Turabelidze G, Sanders-Thompson V, Powderly WG, Geng EH. Quantifying inequities in COVID-19 vaccine distribution over time by social vulnerability, race and ethnicity, and location: A population-level analysis in St. Louis and Kansas City, Missouri. PLoS Med 2022; 19:e1004048. [PMID: 36026527 PMCID: PMC9417193 DOI: 10.1371/journal.pmed.1004048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Accepted: 08/02/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Equity in vaccination coverage is a cornerstone for a successful public health response to COVID-19. To deepen understanding of the extent to which vaccination coverage compares with initial strategies for equitable vaccination, we explore primary vaccine series and booster rollout over time and by race/ethnicity, social vulnerability, and geography. METHODS AND FINDINGS We analyzed data from the Missouri Department of Health and Senior Services on all COVID-19 vaccinations administered across 7 counties in the St. Louis region and 4 counties in the Kansas City region. We compared rates of receiving the primary COVID-19 vaccine series and boosters relative to time, race/ethnicity, zip-code-level Social Vulnerability Index (SVI), vaccine location type, and COVID-19 disease burden. We adapted a well-established tool for measuring inequity-the Lorenz curve-to quantify inequities in COVID-19 vaccination relative to these key metrics. Between 15 December 2020 and 15 February 2022, 1,763,036 individuals completed the primary series and 872,324 received a booster. During early phases of the primary series rollout, Black and Hispanic individuals from high SVI zip codes were vaccinated at less than half the rate of White individuals from low SVI zip codes, but rates increased over time until they were higher than rates in White individuals after June 2021; Asian individuals maintained high levels of vaccination throughout. Increasing vaccination rates in Black and Hispanic communities corresponded with periods when more vaccinations were offered at small community-based sites such as pharmacies rather than larger health systems and mass vaccination sites. Using Lorenz curves, zip codes in the quartile with the lowest rates of primary series completion accounted for 19.3%, 18.1%, 10.8%, and 8.8% of vaccinations while representing 25% of the total population, cases, deaths, or population-level SVI, respectively. When tracking Gini coefficients, these disparities were greatest earlier during rollout, but improvements were slow and modest and vaccine disparities remained across all metrics even after 1 year. Patterns of disparities for boosters were similar but often of much greater magnitude during rollout in fall 2021. Study limitations include inherent limitations in the vaccine registry dataset such as missing and misclassified race/ethnicity and zip code variables and potential changes in zip code population sizes since census enumeration. CONCLUSIONS Inequities in the initial COVID-19 vaccination and booster rollout in 2 large US metropolitan areas were apparent across racial/ethnic communities, across levels of social vulnerability, over time, and across types of vaccination administration sites. Disparities in receipt of the primary vaccine series attenuated over time during a period in which sites of vaccination administration diversified, but were recapitulated during booster rollout. These findings highlight how public health strategies from the outset must directly target these deeply embedded structural and systemic determinants of disparities and track equity metrics over time to avoid perpetuating inequities in healthcare access.
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Affiliation(s)
- Aaloke Mody
- Washington University School of Medicine, St. Louis, Missouri, United States of America
| | - Cory Bradley
- Washington University School of Medicine, St. Louis, Missouri, United States of America
| | - Salil Redkar
- Washington University School of Medicine, St. Louis, Missouri, United States of America
| | - Branson Fox
- Washington University School of Medicine, St. Louis, Missouri, United States of America
| | - Ingrid Eshun-Wilson
- Washington University School of Medicine, St. Louis, Missouri, United States of America
| | | | - Anne Trolard
- Washington University School of Medicine, St. Louis, Missouri, United States of America
- Institute for Public Health, Washington University in St. Louis, St. Louis, Missouri, United States of America
| | - Khai Hoan Tram
- University of Washington School of Medicine, Seattle, Washington, United States of America
| | - Lindsey M. Filiatreau
- Washington University School of Medicine, St. Louis, Missouri, United States of America
| | - Franda Thomas
- St. Louis City Department of Health, St. Louis, Missouri, United States of America
| | - Matt Haslam
- St. Louis City Department of Health, St. Louis, Missouri, United States of America
| | - George Turabelidze
- Missouri Department of Health and Senior Services, Jefferson City and St Louis, Missouri, United States of America
| | - Vetta Sanders-Thompson
- Brown School of Social Work, Washington University in St. Louis, St. Louis, Missouri, United States of America
| | - William G. Powderly
- Washington University School of Medicine, St. Louis, Missouri, United States of America
- Institute for Public Health, Washington University in St. Louis, St. Louis, Missouri, United States of America
| | - Elvin H. Geng
- Washington University School of Medicine, St. Louis, Missouri, United States of America
- Institute for Public Health, Washington University in St. Louis, St. Louis, Missouri, United States of America
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13
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Kerkhoff AD, Chilukutu L, Nyangu S, Kagujje M, Mateyo K, Sanjase N, Eshun-Wilson I, Geng EH, Havlir DV, Muyoyeta M. Patient Preferences for Strategies to Improve Tuberculosis Diagnostic Services in Zambia. JAMA Netw Open 2022; 5:e2229091. [PMID: 36036933 PMCID: PMC9425150 DOI: 10.1001/jamanetworkopen.2022.29091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
IMPORTANCE Delayed engagement in tuberculosis (TB) services is associated with ongoing transmission and poor clinical outcomes. OBJECTIVE To assess whether patients with TB have differential preferences for strategies to improve the public health reach of TB diagnostic services. DESIGN, SETTING, AND PARTICIPANTS A cross-sectional study was undertaken in which a discrete choice experiment (DCE) was administered between September 18, 2019, and January 17, 2020, to 401 adults (>18 years of age) with microbiologically confirmed TB in Lusaka, Zambia. The DCE had 7 attributes with 2 to 3 levels per attribute related to TB service enhancements. Latent class analysis was used to identify segments of participants with unique preferences. Multiscenario simulations were used to estimate shares of preferences for different TB service improvement strategies. MAIN OUTCOMES AND MEASURES The main outcomes were patient preference archetypes and estimated shares of preferences for different strategies to improve TB diagnostic services. Collected data were analyzed between January 3, 2022, to July 2, 2022. RESULTS Among 326 adults with TB (median [IQR] age, 34 [27-42] years; 217 [66.8%] male; 158 [48.8%] HIV positive), 3 groups with distinct preferences for TB service improvements were identified. Group 1 (192 participants [58.9%]) preferred a facility that offered same-day TB test results, shorter wait times, and financial incentives for testing. Group 2 (83 participants [25.4%]) preferred a facility that provided same-day TB results, had greater privacy, and was closer to home. Group 3 (51 participants [15.6%]) had no strong preferences for service improvements and had negative preferences for receiving telephone-based TB test results. Groups 1 and 2 were more likely to report at least a 4-week delay in seeking health care for their current TB episode compared with group 3 (29 [51.3%] in group 1, 95 [35.8%] in group 2, and 10 [19.6%] in group 3; P < .001). Strategies to improve TB diagnostic services most preferred by all participants were same-day TB test results alone (shares of preference, 69.9%) and combined with a small financial testing incentive (shares of preference, 79.3%), shortened wait times (shares of preference, 76.1%), or greater privacy (shares of preference, 75.0%). However, the most preferred service improvement strategies differed substantially by group. CONCLUSIONS AND RELEVANCE In this study, patients with TB had heterogenous preferences for TB diagnostic service improvements associated with differential health care-seeking behavior. Tailored strategies that incorporate features most valued by persons with undiagnosed TB, including same-day results, financial incentives, and greater privacy, may optimize reach by overcoming key barriers to timely TB care engagement.
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Affiliation(s)
- Andrew D. Kerkhoff
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco School of Medicine, San Francisco
| | | | - Sarah Nyangu
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Mary Kagujje
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Kondwelani Mateyo
- Department of Internal Medicine, University Teaching Hospital, Lusaka, Zambia
| | - Nsala Sanjase
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Ingrid Eshun-Wilson
- Division of Infectious Diseases, Washington University School of Medicine, St Louis, Missouri
| | - Elvin H. Geng
- Division of Infectious Diseases, Washington University School of Medicine, St Louis, Missouri
| | - Diane V. Havlir
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco School of Medicine, San Francisco
| | - Monde Muyoyeta
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
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14
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Schwartz S, Ortiz JC, Smith JD, Beres L, Mody A, Eshun-Wilson I, Benbow N, Mallela DP, Tan S, Baral S, Geng E. Data Velocity in HIV-Related Implementation Research: Estimating Time From Funding to Publication. J Acquir Immune Defic Syndr 2022; 90:S32-S40. [PMID: 35703753 PMCID: PMC9204847 DOI: 10.1097/qai.0000000000002963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Given available effective biomedical and behavioral prevention and treatment interventions, HIV-related implementation research (IR) is expanding. The rapid generation and dissemination of IR to inform guidelines and practice has the potential to optimize the impact of the Ending the Epidemic Initiative and the HIV pandemic response more broadly. METHODS We leveraged a prior mapping review of NIH-funded awards in HIV and IR from January 2013 to March 2018 and identified all publications linked to those grants in NIH RePORTER through January 1, 2021 (n = 1509). Deduplication and screening of nonoriginal research reduced the count to 1032 articles, of which 952 were eligible and included in this review. Publication volume and timing were summarized; Kaplan-Meier plots estimated time to publication. RESULTS Among the 215 NIH-funded IR-related awards, 127 of 215 (59%) published original research directly related to the grant, averaging 2.0 articles (SD: 3.3) per award, largely in the early IR phases. Many articles (521 of 952, 55%) attributed to grants did not report grant-related data. Time from article submission to publication averaged 205 days (SD: 107). The median time-to-first publication from funding start was 4 years. Data dissemination velocity varied by award type, trending toward faster publication in recent years. Delays in data velocity included (1) time from funding to enrollment, (2) enrollment length, and (3) time from data collection completion to publication. CONCLUSION Research publication was high overall, and time-to-publication is accelerating; however, over 40% of grants have yet to publish findings from grant-related data. Addressing bottlenecks in the production and dissemination of HIV-related IR would reinforce its programmatic and policy relevance in the HIV response.
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Affiliation(s)
- Sheree Schwartz
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
| | - Joel Chavez Ortiz
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
| | - Justin D. Smith
- Department of Population Health Sciences, University of Utah, Spencer Fox Eccles School of Medicine, Salt Lake City, UT
| | - Laura Beres
- Department of International Health, Johns Hopkins School of Public Health, Baltimore, MD
| | - Aaloke Mody
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO
| | - Ingrid Eshun-Wilson
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO
| | - Nanette Benbow
- Department of Psychiatry and Behavioral Sciences at the Northwestern University Feinberg School of Medicine
| | | | - Stephen Tan
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
| | - Stefan Baral
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
| | - Elvin Geng
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO
- Center for Dissemination and Implementation, Institute for Public Health, Washington University in St. Louis, St. Louis, MO
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15
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Tram KH, Saeed S, Bradley C, Fox B, Eshun-Wilson I, Mody A, Geng E. Deliberation, Dissent, and Distrust: Understanding Distinct Drivers of Coronavirus Disease 2019 Vaccine Hesitancy in the United States. Clin Infect Dis 2022; 74:1429-1441. [PMID: 34272559 PMCID: PMC8406882 DOI: 10.1093/cid/ciab633] [Citation(s) in RCA: 59] [Impact Index Per Article: 29.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Despite the availability of safe and efficacious coronavirus disease 2019 vaccines, a significant proportion of the American public remains unvaccinated and does not appear to be immediately interested in receiving the vaccine. METHODS In this study, we analyzed data from the US Census Bureau's Household Pulse Survey, a biweekly cross-sectional survey of US households. We estimated the prevalence of vaccine hesitancy across states and nationally and assessed the predictors of vaccine hesitancy and vaccine rejection. In addition, we examined the underlying reasons for vaccine hesitancy, grouped into thematic categories. RESULTS A total of 459 235 participants were surveyed from 6 January to 29 March 2021. While vaccine uptake increased from 7.7% to 47%, vaccine hesitancy rates remained relatively fixed: overall, 10.2% reported that they would probably not get a vaccine and 8.2% that they would definitely not get a vaccine. Income, education, and state political leaning strongly predicted vaccine hesitancy. However, while both female sex and black race were factors predicting hesitancy, among those who were hesitant, these same characteristics predicted vaccine reluctance rather than rejection. Those who expressed reluctance invoked mostly "deliberative" reasons, while those who rejected the vaccine were also likely to invoke reasons of "dissent" or "distrust." CONCLUSIONS Vaccine hesitancy comprises a sizable proportion of the population and is large enough to threaten achieving herd immunity. Distinct subgroups of hesitancy have distinctive sociodemographic associations as well as cognitive and affective predilections. Segmented public health solutions are needed to target interventions and optimize vaccine uptake.
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Affiliation(s)
- Khai Hoan Tram
- Division of Infectious Diseases, Department of Medicine,
Washington University in St Louis, St Louis,
Missouri, USA
| | - Sahar Saeed
- Division of Infectious Diseases, Department of Medicine,
Washington University in St Louis, St Louis,
Missouri, USA
| | - Cory Bradley
- Division of Infectious Diseases, Department of Medicine,
Washington University in St Louis, St Louis,
Missouri, USA
| | - Branson Fox
- Division of Infectious Diseases, Department of Medicine,
Washington University in St Louis, St Louis,
Missouri, USA
| | - Ingrid Eshun-Wilson
- Division of Infectious Diseases, Department of Medicine,
Washington University in St Louis, St Louis,
Missouri, USA
| | - Aaloke Mody
- Division of Infectious Diseases, Department of Medicine,
Washington University in St Louis, St Louis,
Missouri, USA
| | - Elvin Geng
- Division of Infectious Diseases, Department of Medicine,
Washington University in St Louis, St Louis,
Missouri, USA
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16
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Le Tourneau N, Germann A, Thompson RR, Ford N, Schwartz S, Beres L, Mody A, Baral S, Geng EH, Eshun-Wilson I. Evaluation of HIV treatment outcomes with reduced frequency of clinical encounters and antiretroviral treatment refills: A systematic review and meta-analysis. PLoS Med 2022; 19:e1003959. [PMID: 35316272 PMCID: PMC8982898 DOI: 10.1371/journal.pmed.1003959] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 04/05/2022] [Accepted: 03/04/2022] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Global HIV treatment programs have sought to lengthen the interval between clinical encounters for people living with HIV (PLWH) who are established on antiretroviral treatment (ART) to reduce the burden of seeking care and to decongest health facilities. The overall effect of reduced visit frequency on HIV treatment outcomes is however unknown. We conducted a systematic review and meta-analysis to evaluate the effect of implementation strategies that reduce the frequency of clinical appointments and ART refills for PLWH established on ART. METHODS AND FINDINGS We searched databases between 1 January 2010 and 9 November 2021 to identify randomized controlled trials (RCTs) and observational studies that compared reduced (6- to 12-monthly) clinical consultation or ART refill appointment frequency to 3- to 6-monthly appointments for patients established on ART. We assessed methodological quality and real-world relevance, and used Mantel-Haenszel methods to generate pooled risk ratios (RRs) with 95% confidence intervals for retention, viral suppression, and mortality. We evaluated heterogeneity quantitatively and qualitatively, and overall evidence certainty using GRADE. Searches yielded 3,955 records, resulting in 10 studies (6 RCTs, 3 observational studies, and 1 study contributing observational and RCT data) representing 15 intervention arms with 33,599 adults (≥16 years) in 8 sub-Saharan African countries. Reduced frequency clinical consultations occurred at health facilities, while reduced frequency ART refills were delivered through facility or community pharmacies and adherence groups. Studies were highly pragmatic, except for some study settings and resources used in RCTs. Among studies comparing reduced clinical consultation frequency (6- or 12-monthly) to 3-monthly consultations, there appeared to be no difference in retention (RR 1.01, 95% CI 0.97-1.04, p = 0.682, 8 studies, low certainty), and this finding was consistent across 6- and 12-monthly consultation intervals and delivery strategies. Viral suppression effect estimates were markedly influenced by under-ascertainment of viral load outcomes in intervention arms, resulting in inconclusive evidence. There was similarly insufficient evidence to draw conclusions on mortality (RR 1.12, 95% CI 0.75-1.66, p = 0.592, 6 studies, very low certainty). For ART refill frequency, there appeared to be little to no difference in retention (RR 1.01, 95% CI 0.98-1.06, p = 0.473, 4 RCTs, moderate certainty) or mortality (RR 1.45, 95% CI 0.63-3.35, p = 0.382, 4 RCTs, low certainty) between 6-monthly and 3-monthly visits. Similar to the analysis for clinical consultations, although viral suppression appeared to be better in 3-monthly arms, effect estimates were markedly influence by under-ascertainment of viral load outcomes in intervention arms, resulting in overall inclusive evidence. This systematic review was limited by the small number of studies available to compare 12- versus 6-monthly clinical consultations, insufficient data to compare implementation strategies, and lack of evidence for children, key populations, and low- and middle-income countries outside of sub-Saharan Africa. CONCLUSIONS Based on this synthesis, extending clinical consultation intervals to 6 or 12 months and ART dispensing intervals to 6 months appears to result in similar retention to 3-month intervals, with less robust conclusions for viral suppression and mortality. Future research should ensure complete viral load outcome ascertainment, as well as explore mechanisms of effect, outcomes in other populations, and optimum delivery and monitoring strategies to ensure widespread applicability of reduced frequency visits across settings.
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Affiliation(s)
- Noelle Le Tourneau
- Division of Infectious Diseases, School of Medicine, Washington University in St. Louis, Saint Louis, Missouri, United States of America
- * E-mail:
| | - Ashley Germann
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Ryan R. Thompson
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Nathan Ford
- Department of Global HIV, Hepatitis and Sexually Transmitted Diseases, World Health Organization, Geneva, Switzerland
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Sheree Schwartz
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Laura Beres
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Aaloke Mody
- Division of Infectious Diseases, School of Medicine, Washington University in St. Louis, Saint Louis, Missouri, United States of America
| | - Stefan Baral
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Elvin H. Geng
- Division of Infectious Diseases, School of Medicine, Washington University in St. Louis, Saint Louis, Missouri, United States of America
- Center for Dissemination and Implementation, Institute for Public Health, Washington University in St. Louis, Saint Louis, Missouri, United States of America
| | - Ingrid Eshun-Wilson
- Division of Infectious Diseases, School of Medicine, Washington University in St. Louis, Saint Louis, Missouri, United States of America
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17
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Mirzazadeh A, Eshun-Wilson I, Thompson RR, Bonyani A, Kahn JG, Baral SD, Schwartz S, Rutherford G, Geng EH. Interventions to reengage people living with HIV who are lost to follow-up from HIV treatment programs: A systematic review and meta-analysis. PLoS Med 2022; 19:e1003940. [PMID: 35290369 PMCID: PMC8923443 DOI: 10.1371/journal.pmed.1003940] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Accepted: 02/08/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Optimizing services to facilitate engagement and retention in care of people living with HIV (PLWH) on antiretroviral therapies (ARTs) is critical to decrease HIV-related morbidity and mortality and HIV transmission. We systematically reviewed the literature for the effectiveness of implementation strategies to reestablish and subsequently retain clinical contact, improve viral load suppression, and reduce mortality among patients who had been lost to follow-up (LTFU) from HIV services. METHODS AND FINDINGS We searched 7 databases (PubMed, Cochrane, ERIC, PsycINFO, EMBASE, Web of Science, and the WHO regional databases) and 3 conference abstract archives (CROI, IAC, and IAS) to find randomized trials and observational studies published through 13 April 2020. Eligible studies included those involving children and adults who were diagnosed with HIV, had initiated ART, and were subsequently lost to care and that reported at least one review outcome (return to care, retention, viral suppression, or mortality). Data were extracted by 2 reviewers, with discrepancies resolved by a third. We characterized reengagement strategies according to how, where, and by whom tracing was conducted. We explored effects, first, among all categorized as LTFU from the HIV program (reengagement program effect) and second among those found to be alive and out of care (reengagement contact outcome). We used random-effect models for meta-analysis and conducted subgroup analyses to explore heterogeneity. Searches yielded 4,244 titles, resulting in 37 included studies (6 randomized trials and 31 observational studies). In low- and middle-income countries (LMICs) (N = 16), tracing most frequently involved identification of LTFU from the electronic medical record (EMR) and paper records followed by a combination of telephone calls and field tracing (including home visits), by a team of outreach workers within 3 months of becoming LTFU (N = 7), with few incorporating additional strategies to support reengagement beyond contact (N = 2). In high-income countries (HICs) (N = 21 studies), LTFU were similarly identified through EMR systems, at times matched with other public health records (N = 4), followed by telephone calls and letters sent by mail or email and conducted by outreach specialist teams. Home visits were less common (N = 7) than in LMICs, and additional reengagement support was similarly infrequent (N = 5). Overall, reengagement programs were able to return 39% (95% CI: 31% to 47%) of all patients who were characterized as LTFU (n = 29). Reengagement contact resulted in 58% (95% CI: 51% to 65%) return among those found to be alive and out of care (N = 17). In 9 studies that had a control condition, the return was higher among those in the reengagement intervention group than the standard of care group (RR: 1.20 (95% CI: 1.08 to 1.32, P < 0.001). There were insufficient data to generate pooled estimates of retention, viral suppression, or mortality after the return. CONCLUSIONS While the types of interventions are markedly heterogeneity, reengagement interventions increase return to care. HIV programs should consider investing in systems to better characterize LTFU to identify those who are alive and out of care, and further research on the optimum time to initiate reengagement efforts after missed visits and how to best support sustained reengagement could improve efficiency and effectiveness.
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Affiliation(s)
- Ali Mirzazadeh
- Division of Infectious Disease and Global Epidemiology, Department of Epidemiology and Biostatistics, and Institute for Global Health Sciences, University of California San Francisco, San Francisco, California, United States of America
- * E-mail:
| | - Ingrid Eshun-Wilson
- Division of Infectious Diseases, School of Medicine, Washington University at St Louis, St Louis, Missouri, United States of America
| | - Ryan R. Thompson
- Francis I. Proctor Foundation, University of California San Francisco, San Francisco, California, United States of America
| | | | - James G. Kahn
- University of California San Francisco, San Francisco, California, United States of America
| | - Stefan D. Baral
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Sheree Schwartz
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - George Rutherford
- Division of Infectious Disease and Global Epidemiology, Department of Epidemiology and Biostatistics, and Institute for Global Health Sciences, University of California San Francisco, San Francisco, California, United States of America
| | - Elvin H. Geng
- Division of Infectious Diseases, School of Medicine, Washington University at St Louis, St Louis, Missouri, United States of America
- Center for Dissemination and Implementation, Institute for Public Health, Washington University in St. Louis, St Louis, Missouri, United States of America
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18
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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 Glob 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] [What about the content of this article? (0)] [Affiliation(s)] [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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19
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Beres LK, Mody A, Sikombe K, Nicholas LH, Schwartz S, Eshun-Wilson I, Somwe P, Simbeza S, Pry JM, Kaumba P, McGready J, Holmes CB, Bolton-Moore C, Sikazwe I, Denison JA, Geng EH. The effect of tracer contact on return to care among adult, "lost to follow-up" patients living with HIV in Zambia: an instrumental variable analysis. J Int AIDS Soc 2021; 24:e25853. [PMID: 34921515 PMCID: PMC8683971 DOI: 10.1002/jia2.25853] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 11/17/2021] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Tracing patients lost to follow-up (LTFU) from HIV care is widely practiced, yet we have little knowledge of its causal effect on care engagement. In a prospective, Zambian cohort, we examined the effect of tracing on return to care within 2 years of LTFU. METHODS We traced a stratified, random sample of LTFU patients who had received HIV care between August 2013 and July 2015. LTFU was defined as a gap of >90 days from last scheduled appointment in the routine electronic medical record. Extracting 2 years of follow-up visit data through 2017, we identified patients who returned. Using random selection for tracing as an instrumental variable (IV), we used conditional two-stage least squares regression to estimate the local average treatment effect of tracer contact on return. We examined the observational association between tracer contact and return among patient sub-groups self-confirmed as disengaged from care. RESULTS Of the 24,164 LTFU patients enumerated, 4380 were randomly selected for tracing and 1158 were contacted by a tracer within a median of 14.8 months post-loss. IV analysis found that patients contacted by a tracer because they were randomized to tracing were no more likely to return than those not contacted (adjusted risk difference [aRD]: 3%, 95% CI: -2%, 8%, p = 0.23). Observational data showed that among contacted, disengaged patients, the rate of return was higher in the week following tracer contact (IR 5.74, 95% CI: 3.78-8.71) than in the 2 weeks to 1-month post-contact (IR 2.28, 95% CI: 1.40-3.72). There was a greater effect of tracing among patients lost for >6 months compared to those contacted within 3 months of loss. CONCLUSIONS Overall, tracer contact did not causally increase LTFU patient return to HIV care, demonstrating the limited impact of tracing in this program, where contact occurred months after patients were LTFU. However, observational data suggest that tracing may speed return among some LTFU patients genuinely out-of-care. Further studies may improve tracing effectiveness by examining the mechanisms underlying the impact of tracing on return to care, the effect of tracing at different times-since-loss and using more accurate identification of patients who are truly disengaged to target tracing.
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Affiliation(s)
- Laura K Beres
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Aaloke Mody
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | | | - Lauren Hersch Nicholas
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Sheree Schwartz
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Ingrid Eshun-Wilson
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Paul Somwe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Sandra Simbeza
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Jake M Pry
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA.,Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Paul Kaumba
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - John McGready
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Charles B Holmes
- Center for Innovation in Global Health, Georgetown University, Washington, DC, USA.,Division of Infectious Disease, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Carolyn Bolton-Moore
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.,Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Izukanji Sikazwe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Julie A Denison
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Elvin H Geng
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
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20
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Sikazwe I, Eshun-Wilson I, Sikombe K, Beres LK, Somwe P, Mody A, Simbeza S, Bukankala C, Glidden DV, Mulenga LB, Padian N, Ehrenkranz P, Bolton-Moore C, Holmes CB, Geng EH. Patient-reported Reasons for Stopping Care or Switching Clinics in Zambia: A Multisite, Regionally Representative Estimate Using a Multistage Sampling-based Approach in Zambia. Clin Infect Dis 2021; 73:e2294-e2302. [PMID: 33011803 PMCID: PMC8492131 DOI: 10.1093/cid/ciaa1501] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 10/01/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Understanding patient-reported reasons for lapses of retention in human immunodeficiency virus (HIV) treatment can drive improvements in the care cascade. A systematic assessment of outcomes among a random sample of patients lost to follow-up (LTFU) from 32 clinics in Zambia to understand the reasons for silent transfers and disengagement from care was undertaken. METHODS We traced a simple random sample of LTFU patients (>90 days from last scheduled visit) as determined from clinic-based electronic medical records from a probability sample of facilities. Among patients found in person, we solicited reasons for either stopping or switching care and predictors for re-engagement. We coded reasons into structural, psychosocial, and clinic-based barriers. RESULTS Among 1751 LTFU patients traced and found alive, 31% of patients starting antiretroviral therapy (ART) between 1 July 2013 and 31 July 2015 silently transferred or were disengaged (40% male; median age, 35 years; median CD4 level, 239 cells/μL); median time on ART at LTFU was 480 days (interquartile range, 110-1295). Among the 544 patients not in care, median prevalences for patient-reported structural, psychosocial, and clinic-level barriers were 27.3%, 13.9%, and 13.4%, respectively, and were highly variable across facilities. Structural reasons, including, "relocated to a new place" were mostly cited among 289 patients who silently transferred (35.5%). We found that men were less likely to re-engage in care than women (odds ratio, .39; 95% confidence interval, .22-.67; P = .001). CONCLUSIONS Efforts to improve retention of patients on ART may need to be tailored at the facility level to address patient-reported barriers.
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Affiliation(s)
- Izukanji Sikazwe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | | | - Kombatende Sikombe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Paul Somwe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Aaloke Mody
- Washington University in St Louis, St Louis, Missouri, USA
| | - Sandra Simbeza
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Chama Bukankala
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | | | | | - Nancy Padian
- University of California Berkeley, Berkeley, California, USA
| | | | | | - Charles B Holmes
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- Johns Hopkins University, Baltimore, Maryland, USA
- Georgetown University, Washington, D.C., USA
| | - Elvin H Geng
- Washington University in St Louis, St Louis, Missouri, USA
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21
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Ford N, Eshun-Wilson I, Ameyan W, Newman M, Vojnov L, Doherty M, Geng E. Future directions for HIV service delivery research: Research gaps identified through WHO guideline development. PLoS Med 2021; 18:e1003812. [PMID: 34555010 PMCID: PMC8496797 DOI: 10.1371/journal.pmed.1003812] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Revised: 10/07/2021] [Indexed: 11/19/2022] Open
Abstract
Nathan Ford and co-authors discuss the systematic identification of research gaps in improving HIV service delivery.
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Affiliation(s)
- Nathan Ford
- Department of HIV, Viral Hepatitis and STIs, World Health Organization, Geneva, Switzerland
| | - Ingrid Eshun-Wilson
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, United States of America
| | - Wole Ameyan
- Department of HIV, Viral Hepatitis and STIs, World Health Organization, Geneva, Switzerland
| | - Morkor Newman
- Department of HIV, Viral Hepatitis and STIs, World Health Organization, Geneva, Switzerland
| | - Lara Vojnov
- Department of HIV, Viral Hepatitis and STIs, World Health Organization, Geneva, Switzerland
| | - Meg Doherty
- Department of HIV, Viral Hepatitis and STIs, World Health Organization, Geneva, Switzerland
| | - Elvin Geng
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, United States of America
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22
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Kerkhoff AD, Kagujje M, Nyangu S, Mateyo K, Sanjase N, Chilukutu L, Eshun-Wilson I, Geng EH, Havlir DV, Muyoyeta M. Pathways to care and preferences for improving tuberculosis services among tuberculosis patients in Zambia: A discrete choice experiment. PLoS One 2021; 16:e0252095. [PMID: 34464392 PMCID: PMC8407587 DOI: 10.1371/journal.pone.0252095] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 05/21/2021] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Delays in the diagnosis of tuberculosis (TB) contribute to a substantial proportion of TB-related mortality, especially among people living with HIV (PLHIV). We sought to characterize the diagnostic journey for HIV-positive and HIV-negative patients with a new TB diagnosis in Zambia, to understand drivers of delay, and characterize their preferences for service characteristics to inform improvements in TB services. METHODS We assessed consecutive adults with newly microbiologically-confirmed TB at two public health treatment facilities in Lusaka, Zambia. We administered a survey to document critical intervals in the TB care pathway (time to initial care-seeking, diagnosis and treatment initiation), identify bottlenecks and their reasons. We quantified patient preferences for a range of characteristics of health services using a discrete choice experiment (DCE) that assessed 7 attributes (distance, wait times, hours of operation, confidentiality, sex of provider, testing incentive, TB test speed and notification method). RESULTS Among 401 patients enrolled (median age of 34 years, 68.7% male, 46.6% HIV-positive), 60.9% and 39.1% were from a first-level and tertiary hospital, respectively. The median time from symptom onset to receipt of TB treatment was 5.0 weeks (IQR: 3.6-8.0) and was longer among HIV-positive patients seeking care at a tertiary hospital than HIV-negative patients (6.4 vs. 4.9 weeks, p = 0.002). The time from symptom onset to initial presentation for evaluation accounted for the majority of time until treatment initiation (median 3.0 weeks, IQR: 1.0-5.0)-an important minority of 11.0% of patients delayed care-seeking ≥8 weeks. The DCE found that patients strongly preferred same-day TB test results (relative importance, 37.2%), facilities close to home (18.0%), and facilities with short wait times (16.9%). Patients were willing to travel to a facility up to 7.6 kilometers further away in order to access same-day TB test results. Preferences for improving current TB services did not differ according to HIV status. CONCLUSIONS Prolonged intervals from TB symptom onset to treatment initiation were common, especially among PLHIV, and were driven by delayed health-seeking. Addressing known barriers to timely diagnosis and incorporating patients' preferences into TB services, including same-day TB test results, may facilitate earlier TB care engagement in high burden settings.
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Affiliation(s)
- Andrew D. Kerkhoff
- Division of HIV, Infectious Diseases and Global Medicine Zuckerberg San Francisco General Hospital and Trauma Center University of California, San Francisco, California, United States of America
| | - Mary Kagujje
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Sarah Nyangu
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Kondwelani Mateyo
- University Teaching Hospital, Department of Internal Medicine, Lusaka, Zambia
| | - Nsala Sanjase
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | | | - Ingrid Eshun-Wilson
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, United States of America
| | - Elvin H. Geng
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, United States of America
| | - Diane V. Havlir
- Division of HIV, Infectious Diseases and Global Medicine Zuckerberg San Francisco General Hospital and Trauma Center University of California, San Francisco, California, United States of America
| | - Monde Muyoyeta
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
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Dommaraju S, Hagey J, Odeny TA, Okaka S, Kadima J, Bukusi EA, Cohen CR, Kwena Z, Eshun-Wilson I, Geng E. Preferences of people living with HIV for differentiated care models in Kenya: A discrete choice experiment. PLoS One 2021; 16:e0255650. [PMID: 34432795 PMCID: PMC8386850 DOI: 10.1371/journal.pone.0255650] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 07/21/2021] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION To improve retention on HIV treatment in Africa, public health programs are promoting a family of innovations to service delivery-referred to as "differentiated service delivery" (DSD) models-which seek to better meet the needs of both systems and patients by reducing unnecessary encounters, expanding access, and incorporating peers and patients in patient care. Data on the relative desirability of different models to target populations, which is currently sparse, can help guide prioritization of specific models during scale-up. METHODS We conducted a discrete choice experiment to assess patient preferences for various characteristics of treatment services. Clinically stable people living with HIV were recruited from an HIV clinic in Kisumu, Kenya. We selected seven attributes of DSD models drawn from literature review and previous qualitative work. We created a balanced and orthogonal design to identify main term effects. A total of ten choice tasks were solicited per respondent. We calculated relative utility (RU) for each attribute level, a numerical representation of the strength of patient preference. Data were analyzed using a Hierarchical Bayesian model via Sawtooth Software. RESULTS One hundred and four respondents (37.5% men, 41.1 years mean age) preferred receiving care at a health facility, compared with home-delivery or a community meeting point (RU = 69.3, -16.2, and -53.1, respectively; p << 0.05); receiving those services from clinicians and pharmacists-as opposed to lay health workers or peers (RU = 21.5, 5.9, -24.5; p < 0.05); and preferred an individual support system over a group support system (RU = 15.0 and 4.2; p < 0.05). Likewise, patients strongly preferred longer intervals between both clinical reviews (RU = 40.1 and -50.7 for 6- and 1-month spacing, respectively; p < 0.05) and between ART collections (RU = 33.6 and -49.5 for 6- and1-month spacing, respectively; p < 0.05). CONCLUSION Although health systems find community- and peer-based DSD models attractive, clinically stable patients expressed a preference for facility-based care as long as clinical visits were extended to biannual. These data suggest that multi-month scripting and fast-track models best align with patient preferences, an insight which can help prioritize use of different DSD models in the region.
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Affiliation(s)
- Sagar Dommaraju
- Department of Global Health, University of California San Francisco, San Francisco, California, United States of America
| | - Jill Hagey
- Department of Obstetrics and Gynecology, Duke University Hospital, Durham, North Carolina, United States of America
| | - Thomas A. Odeny
- Department of Medicine, University of Missouri-Kansas City, Kansas City, Missouri, United States of America
- Kenya Medical Research Institute, Nairobi, Kenya
| | - Sharon Okaka
- Kenya Medical Research Institute, Nairobi, Kenya
| | - Julie Kadima
- Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Craig R. Cohen
- Department of Global Health, University of California San Francisco, San Francisco, California, United States of America
- Department of Medicine, University of California San Francisco, San Francisco, California, United States of America
| | | | - Ingrid Eshun-Wilson
- Department of Medicine, University of California San Francisco, San Francisco, California, United States of America
| | - Elvin Geng
- Department of Medicine, University of California San Francisco, San Francisco, California, United States of America
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Jamil MS, Eshun-Wilson I, Witzel TC, Siegfried N, Figueroa C, Chitembo L, Msimanga-Radebe B, Pasha MS, Hatzold K, Corbett E, Barr-DiChiara M, Rodger AJ, Weatherburn P, Geng E, Baggaley R, Johnson C. Examining the effects of HIV self-testing compared to standard HIV testing services in the general population: A systematic review and meta-analysis. EClinicalMedicine 2021; 38:100991. [PMID: 34278282 PMCID: PMC8271120 DOI: 10.1016/j.eclinm.2021.100991] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Revised: 06/08/2021] [Accepted: 06/10/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND We updated a 2017 systematic review and compared the effects of HIV self-testing (HIVST) to standard HIV testing services to understand effective service delivery models among the general population. METHODS We included randomized controlled trials (RCTs) comparing testing outcomes with HIVST to standard testing in the general population and published between January 1, 2006 and June 4, 2019. Random effects meta-analysis was conducted and pooled risk ratios (RRs) were reported. The certainty of evidence was determined using the GRADE methodology. FINDINGS We identified 14 eligible RCTs, 13 of which were conducted in sub-Saharan Africa. Support provided to self-testers ranged from no/basic support to one-on-one in-person support. HIVST increased testing uptake overall (RR:2.09; 95% confidence interval: 1.69-2.58; p < 0.0001;13 RCTs; moderate certainty evidence) and by service delivery model including facility-based distribution, HIVST use at facilities, secondary distribution to partners, and community-based distribution. The number of persons diagnosed HIV-positive among those tested (RR:0.81, 0.45-1.47; p = 0.50; 8 RCTs; moderate certainty evidence) and number linked to HIV care/treatment among those diagnosed (RR:0.95, 0.79-1.13; p = 0.52; 6 RCTs; moderate certainty evidence) were similar between HIVST and standard testing. Reported harms/adverse events with HIVST were rare and appeared similar to standard testing (RR:2.52: 0.52-12.13; p = 0.25; 4 RCTs; very low certainty evidence). INTERPRETATION HIVST appears to be safe and effective among the general population in sub-Saharan Africa with a range of delivery models. It identified and linked additional people with HIV to care. These findings support the wider availability of HIVST to reach those who may not otherwise access testing.
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Affiliation(s)
- Muhammad S. Jamil
- Global HIV, Hepatitis and STIs Programmes, World Health Organization, Geneva, Switzerland
- Corresponding author.
| | - Ingrid Eshun-Wilson
- Washington University School of Medicine in St. Louis, St Louis, United States
| | - T. Charles Witzel
- Department of Public Health, Environments & Society, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Nandi Siegfried
- Independent Clinical Epidemiologist, Cape Town, South Africa
| | - Carmen Figueroa
- Global HIV, Hepatitis and STIs Programmes, World Health Organization, Geneva, Switzerland
| | - Lastone Chitembo
- World Health Organization Country Office for Zambia, Lusaka, Zambia
| | | | - Muhammad S. Pasha
- World Health Organization Country Office for Pakistan, Islamabad, Pakistan
| | - Karin Hatzold
- Population Services International, Cape Town, South Africa
| | - Elizabeth Corbett
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, United Kingdom
- TB/HIV Group, Malawi–Liverpool–Wellcome Clinical Research Programme, Blantyre, Malawi
| | | | - Alison J. Rodger
- Institute for Global Health, University College London, London, United Kingdom
| | - Peter Weatherburn
- Department of Public Health, Environments & Society, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Elvin Geng
- Washington University School of Medicine in St. Louis, St Louis, United States
| | - Rachel Baggaley
- Global HIV, Hepatitis and STIs Programmes, World Health Organization, Geneva, Switzerland
| | - Cheryl Johnson
- Global HIV, Hepatitis and STIs Programmes, World Health Organization, Geneva, Switzerland
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Mody A, Tram KH, Glidden DV, Eshun-Wilson I, Sikombe K, Mehrotra M, Pry JM, Geng EH. Novel Longitudinal Methods for Assessing Retention in Care: a Synthetic Review. Curr HIV/AIDS Rep 2021; 18:299-308. [PMID: 33948789 DOI: 10.1007/s11904-021-00561-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/21/2021] [Indexed: 01/22/2023]
Abstract
PURPOSE OF REVIEW Retention in care is both dynamic and longitudinal in nature, but current approaches to retention often reduce these complex histories into cross-sectional metrics that obscure the nuanced experiences of patients receiving HIV care. In this review, we discuss contemporary approaches to assessing retention in care that captures its dynamic nature and the methodological and data considerations to do so. RECENT FINDINGS Enhancing retention measurements either through patient tracing or "big data" approaches (including probabilistic matching) to link databases from different sources can be used to assess longitudinal retention from the perspective of the patient when they transition in and out of care and access care at different facilities. Novel longitudinal analytic approaches such as multi-state and group-based trajectory analyses are designed specifically for assessing metrics that can change over time such as retention in care. Multi-state analyses capture the transitions individuals make in between different retention states over time and provide a comprehensive depiction of longitudinal population-level outcomes. Group-based trajectory analyses can identify patient subgroups that follow distinctive retention trajectories over time and highlight the heterogeneity of retention patterns across the population. Emerging approaches to longitudinally measure retention in care provide nuanced assessments that reveal unique insights into different care gaps at different time points over an individuals' treatment. These methods help meet the needs of the current scientific agenda for retention and reveal important opportunities for developing more tailored interventions that target the varied care challenges patients may face over the course of lifelong treatment.
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Affiliation(s)
- Aaloke Mody
- Division of Infectious Diseases, Washington University School of Medicine, Campus Box 8051, 4523 Clayton Avenue, St. Louis, Missouri, 63110, USA.
| | - Khai Hoan Tram
- Division of Infectious Diseases, Washington University School of Medicine, Campus Box 8051, 4523 Clayton Avenue, St. Louis, Missouri, 63110, USA
| | - David V Glidden
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | - Ingrid Eshun-Wilson
- Division of Infectious Diseases, Washington University School of Medicine, Campus Box 8051, 4523 Clayton Avenue, St. Louis, Missouri, 63110, USA
| | - Kombatende Sikombe
- Centre for Infectious Diseases Research in Zambia, Lusaka, Zambia
- Department of Public Health Environments and Society, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Megha Mehrotra
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | - Jake M Pry
- Division of Infectious Diseases, Washington University School of Medicine, Campus Box 8051, 4523 Clayton Avenue, St. Louis, Missouri, 63110, USA
- Centre for Infectious Diseases Research in Zambia, Lusaka, Zambia
| | - Elvin H Geng
- Division of Infectious Diseases, Washington University School of Medicine, Campus Box 8051, 4523 Clayton Avenue, St. Louis, Missouri, 63110, USA
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Eshun-Wilson I, Mody A, McKay V, Hlatshwayo M, Bradley C, Thompson V, Glidden DV, Geng EH. Public Preferences for Social Distancing Policy Measures to Mitigate the Spread of COVID-19 in Missouri. JAMA Netw Open 2021; 4:e2116113. [PMID: 34236410 PMCID: PMC8267603 DOI: 10.1001/jamanetworkopen.2021.16113] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
IMPORTANCE Policies to promote social distancing can minimize COVID-19 transmission but come with substantial social and economic costs. Quantifying relative preferences among the public for such practices can inform locally relevant policy prioritization and optimize uptake. OBJECTIVE To evaluate relative utilities (ie, preferences) for COVID-19 pandemic social distancing strategies against the hypothetical risk of acquiring COVID-19 and anticipated income loss. DESIGN, SETTING, AND PARTICIPANTS This survey study recruited individuals living in the Missouri area from May to June 2020 via randomly distributed unincentivized social media advertisements and local recruitment platforms for members of minority racial and ethnic groups. Participants answered 6 questions that asked them to choose between 2 hypothetical counties where business closures, social distancing policy duration, COVID-19 infection risk, and income loss varied. MAIN OUTCOMES AND MEASURES Reweighted population-level relative preferences (utilities) for social distancing policies, subgroups, and latent classes. RESULTS The survey had a 3% response rate (3045 of 90 320). Of the 2428 respondents who completed the survey, 1669 (75%) were 35 years and older, 1536 (69%) were women, and 1973 (89%) were White. After reweighting to match Missouri population demographic characteristics, the strongest preference was for the prohibition of large gatherings (mean preference, -1.43; 95% CI, -1.67 to -1.18), with relative indifference to the closure of social and lifestyle venues (mean preference, 0.05; 95% CI, -0.08 to 0.17). There were weak preferences to keep outdoor venues (mean preference, 0.50; 95% CI, 0.39 to 0.61) and schools (mean preference, 0.18; 95% CI, 0.05 to 0.30) open. Latent class analysis revealed 4 distinct preference phenotypes in the population: risk averse (48.9%), conflicted (22.5%), prosocial (14.9%), and back to normal (13.7%), with men twice as likely as women to belong to the back to normal group than the risk averse group (relative risk ratio, 2.19; 95% CI, 1.54 to 3.12). CONCLUSIONS AND RELEVANCE In this survey study using a discrete choice experiment, public health policies that prohibited large gatherings, as well as those that closed social and lifestyle venues, appeared to be acceptable to the public. During policy implementation, these activities should be prioritized for first-phase closures. These findings suggest that policy messages that address preference heterogeneity (eg, focusing on specific preference subgroups or targeting men) could improve adherence to social distancing measures for COVID-19 and future pandemics.
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Affiliation(s)
- Ingrid Eshun-Wilson
- School of Medicine, Division of Infectious Diseases, Washington University in St Louis, St Louis, Missouri
| | - Aaloke Mody
- School of Medicine, Division of Infectious Diseases, Washington University in St Louis, St Louis, Missouri
| | - Virginia McKay
- Brown School at Washington University in St. Louis, St Louis, Missouri
| | - Matifadza Hlatshwayo
- School of Medicine, Division of Infectious Diseases, Washington University in St Louis, St Louis, Missouri
| | - Cory Bradley
- Center for Dissemination and Implementation Research, Washington University in St Louis, St Louis, Missouri
| | - Vetta Thompson
- Brown School at Washington University in St. Louis, St Louis, Missouri
| | | | - Elvin H. Geng
- School of Medicine, Division of Infectious Diseases, Washington University in St Louis, St Louis, Missouri
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Eshun-Wilson I, Awotiwon AA, Germann A, Amankwaa SA, Ford N, Schwartz S, Baral S, Geng EH. Effects of community-based antiretroviral therapy initiation models on HIV treatment outcomes: A systematic review and meta-analysis. PLoS Med 2021; 18:e1003646. [PMID: 34048443 PMCID: PMC8213195 DOI: 10.1371/journal.pmed.1003646] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 06/18/2021] [Accepted: 05/05/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Antiretroviral therapy (ART) initiation in the community and outside of a traditional health facility has the potential to improve linkage to ART, decongest health facilities, and minimize structural barriers to attending HIV services among people living with HIV (PLWH). We conducted a systematic review and meta-analysis to determine the effect of offering ART initiation in the community on HIV treatment outcomes. METHODS AND FINDINGS We searched databases between 1 January 2013 and 22 February 2021 to identify randomized controlled trials (RCTs) and observational studies that compared offering ART initiation in a community setting to offering ART initiation in a traditional health facility or alternative community setting. We assessed risk of bias, reporting of implementation outcomes, and real-world relevance and used Mantel-Haenszel methods to generate pooled risk ratios (RRs) and risk differences (RDs) with 95% confidence intervals. We evaluated heterogeneity qualitatively and quantitatively and used GRADE to evaluate overall evidence certainty. Searches yielded 4,035 records, resulting in 8 included studies-4 RCTs and 4 observational studies-conducted in Lesotho, South Africa, Nigeria, Uganda, Malawi, Tanzania, and Haiti-a total of 11,196 PLWH. Five studies were conducted in general HIV populations, 2 in key populations, and 1 in adolescents. Community ART initiation strategies included community-based HIV testing coupled with ART initiation at home or at community venues; 5 studies maintained ART refills in the community, and 4 provided refills at the health facility. All studies were pragmatic, but in most cases provided additional resources. Few studies reported on implementation outcomes. All studies showed higher ART uptake in community initiation arms compared to facility initiation and refill arms (standard of care) (RR 1.73, 95% CI 1.22 to 2.45; RD 30%, 95% CI 10% to 50%; 5 studies). Retention (RR 1.43, 95% CI 1.32 to 1.54; RD 19%, 95% CI 11% to 28%; 4 studies) and viral suppression (RR 1.31, 95% CI 1.15 to 1.49; RD 15%, 95% CI 10% to 21%; 3 studies) at 12 months were also higher in the community-based ART initiation arms. Improved uptake, retention, and viral suppression with community ART initiation were seen across population subgroups-including men, adolescents, and key populations. One study reported no difference in retention and viral suppression at 2 years. There were limited data on adherence and mortality. Social harms and adverse events appeared to be minimal and similar between community ART initiation and standard of care. One study compared ART refill strategies following community ART initiation (community versus facility refills) and found no difference in viral suppression (RD -7%, 95% CI -19% to 6%) or retention at 12 months (RD -12%, 95% CI -23% to 0.3%). This systematic review was limited by few studies for inclusion, poor-quality observational data, and short-term outcomes. CONCLUSIONS Based on data from a limited set of studies, community ART initiation appears to result in higher ART uptake, retention, and viral suppression at 1 year compared to facility-based ART initiation. Implementation on a wider scale necessitates broader exploration of costs, logistics, and acceptability by providers and PLWH to ensure that these effects are reproducible when delivered at scale, in different contexts, and over time.
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Affiliation(s)
- Ingrid Eshun-Wilson
- Division of Infectious Diseases, Washington University School of Medicine, Washington University in St. Louis, Saint Louis, Missouri, United States of America
- Division of Epidemiology and Biostatistics, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
| | - Ajibola A. Awotiwon
- Division of Epidemiology and Biostatistics, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
- Knowledge Translation Unit, University of Cape Town Lung Institute, Cape Town, South Africa
| | - Ashley Germann
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Sophia A. Amankwaa
- Division of Epidemiology and Biostatistics, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
| | - Nathan Ford
- Global Hepatitis Programme, Department of HIV/AIDS, World Health Organization, Geneva, Switzerland
| | - Sheree Schwartz
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Stefan Baral
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Elvin H. Geng
- Division of Infectious Diseases, Washington University School of Medicine, Washington University in St. Louis, Saint Louis, Missouri, United States of America
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Beres LK, Schwartz S, Simbeza S, McGready J, Eshun-Wilson I, Mwamba C, Sikombe K, Topp SM, Somwe P, Mody A, Mukamba N, Ehrenkranz PD, Padian N, Pry J, Moore CB, Holmes CB, Sikazwe I, Denison JA, Geng E. Patterns and Predictors of Incident Return to HIV Care Among Traced, Disengaged Patients in Zambia: Analysis of a Prospective Cohort. J Acquir Immune Defic Syndr 2021; 86:313-322. [PMID: 33149000 PMCID: PMC7878284 DOI: 10.1097/qai.0000000000002554] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 09/28/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Dynamic movement of patients in and out of HIV care is prevalent, but there is limited information on patterns of patient re-engagement or predictors of return to guide HIV programs to better support patient engagement. METHODS From a probability-based sample of lost to follow-up, adult patients traced by peer educators from 31 Zambian health facilities, we prospectively followed disengaged HIV patients for return clinic visits. We estimated the cumulative incidence of return and the time to return using Kaplan-Meier methods. We used univariate and multivariable Cox proportional hazards regression to conduct a risk factor analysis identifying predictors of incident return across a social ecological framework. RESULTS Of the 556 disengaged patients, 73.0% [95% confidence interval (CI): 61.0 to 83.8] returned to HIV care. The median follow-up time from disengagement was 32.3 months (interquartile range: 23.6-38.9). The rate of return decreased with time postdisengagement. Independent predictors of incident return included a previous gap in care [adjusted Hazard Ratio (aHR): 1.95, 95% CI: 1.23 to 3.09] and confronting a stigmatizer once in the past year (aHR: 2.14, 95% CI: 1.25 to 3.65). Compared with a rural facility, patients were less likely to return if they sought care from an urban facility (aHR: 0.68, 95% CI: 0.48 to 0.96) or hospital (aHR: 0.52, 95% CI: 0.33 to 0.82). CONCLUSIONS Interventions are needed to hasten re-engagement in HIV care. Early and differential interventions by time since disengagement may improve intervention effectiveness. Patients in urban and tertiary care settings may need additional support. Improving patient resilience, outreach after a care gap, and community stigma reduction may facilitate return. Future re-engagement research should include causal evaluation of identified factors.
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Affiliation(s)
- Laura K. Beres
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD;
| | - Sheree Schwartz
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Sandra Simbeza
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia;
| | - John McGready
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Ingrid Eshun-Wilson
- Division of Infectious Diseases, Washington University School of Medicine, University of Washington, St. Louis, St. Louis, MO
| | - Chanda Mwamba
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia;
| | | | - Stephanie M. Topp
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, Australia;
| | - Paul Somwe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia;
| | - Aaloke Mody
- Division of Infectious Diseases, Washington University School of Medicine, University of Washington, St. Louis, St. Louis, MO
| | - Njekwa Mukamba
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia;
| | | | - Nancy Padian
- Division of Epidemiology, University of California Berkeley, Berkeley, CA; and
| | - Jake Pry
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia;
- Division of Infectious Diseases, Washington University School of Medicine, University of Washington, St. Louis, St. Louis, MO
| | - Carolyn Bolton Moore
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia;
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, AL
| | - Charles B. Holmes
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD;
- Department of Medicine, Georgetown University, Washington, DC
| | - Izukanji Sikazwe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia;
| | - Julie A. Denison
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD;
| | - Elvin Geng
- Division of Infectious Diseases, Washington University School of Medicine, University of Washington, St. Louis, St. Louis, MO
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Hendricks L, Eshun-Wilson I, Rohwer A. A mega-aggregation framework synthesis of the barriers and facilitators to linkage, adherence to ART and retention in care among people living with HIV. Syst Rev 2021; 10:54. [PMID: 33568216 PMCID: PMC7875685 DOI: 10.1186/s13643-021-01582-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 01/06/2021] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND People living with human immunodeficiency virus (PLHIV) struggle with the challenges of living with a chronic disease and integrating antiretroviral treatment (ART) and care into their daily lives. The aims of this study were as follows: (1) to undertake the first mega-aggregation of qualitative evidence syntheses using the methods of framework synthesis and (2) make sense of existing qualitative evidence syntheses that explore the barriers and facilitators of adherence to antiretroviral treatment, linkage to care and retention in care for PLHIV to identify research gaps. METHODS We conducted a comprehensive search and did all screening, data extraction and critical appraisal independently and in duplicate. We used the Kaufman HIV Behaviour Change model (Kaufman et al., 2014) as a framework to synthesise the findings using the mega-aggregative framework synthesis approach, which consists of 8 steps: (1) identify a clearly defined review question and objectives, (2) identify a theoretical framework or model, (3) decide on criteria for considering reviews for inclusion, (4) conduct searching and screening, (5) conduct quality appraisal of the included studies, (6) data extraction and categorisation, (7) present and synthesise the findings, and (8) transparent reporting. We evaluated systematic reviews up to July 2018 and assessed methodological quality, across reviews, using the Joanna Briggs Institute Critical Appraisal Checklist for Systematic Reviews. RESULTS We included 33 systematic reviews from low, middle- and high-income countries, which reported on 1,111,964 PLHIV. The methodological quality of included reviews varied considerably. We identified 544 unique third-order concepts from the included systematic reviews, which were reclassified into 45 fourth-order themes within the individual, interpersonal, community, institutional and structural levels of the Kaufman HIV Behaviour Change model. We found that the main influencers of linkage, adherence and retention behaviours were psychosocial and personal characteristics-perceptions of ART, desires, fears, experiences of HIV and ART, coping strategies and mental health issues-interwoven with other factors on the interpersonal, community, institutional and structural level. Using this approach, we found interdependence between factors influencing ART linkage, retention and adherence and identified the need for qualitative evidence that explores, in greater depth, the complex relationships between structural factors and adherence, sociodemographic factors such as community violence and retention, and the experiences of growing up with HIV in low- and middle-income countries-specifically in children, youth, women and key populations. CONCLUSIONS This is the first mega-aggregation framework synthesis, or synthesis of qualitative evidence syntheses using the methods of framework synthesis at the overview level. We found the novel method to be a transparent and efficient method for assessing the quality and making sense of existing qualitative systematic reviews. SYSTEMATIC REVIEW REGISTRATION The protocol of this overview was registered on PROSPERO ( CRD42017078155 ) on 17 December 2017.
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Affiliation(s)
- Lynn Hendricks
- Centre for Evidence-Based Health Care, Division Epidemiology and Biostatistics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Social, Methodological, Innovative, Kreative, Centre for Sociological Research, Faculty of Social Sciences, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Ingrid Eshun-Wilson
- Centre for Evidence-Based Health Care, Division Epidemiology and Biostatistics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Anke Rohwer
- Centre for Evidence-Based Health Care, Division Epidemiology and Biostatistics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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Eshun-Wilson I, Jamil MS, Witzel TC, Glidded DV, Johnson C, Le Trouneau N, Ford N, McGee K, Kemp C, Baral S, Schwartz S, Geng EH. A Systematic Review and Network Meta-analyses to Assess the Effectiveness of Human Immunodeficiency Virus (HIV) Self-testing Distribution Strategies. Clin Infect Dis 2021; 73:e1018-e1028. [PMID: 34398952 PMCID: PMC8366833 DOI: 10.1093/cid/ciab029] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Indexed: 12/02/2022] Open
Abstract
Background We conducted a systematic review and network meta-analysis to identify which human immunodeficiency virus (HIV) self-testing (HIVST) distribution strategies are most effective. Methods We abstracted data from randomized controlled trials and observational studies published between 4 June 2006 and 4 June 2019. Results We included 33 studies, yielding 6 HIVST distribution strategies. All distribution strategies increased testing uptake compared to standard testing: in sub-Saharan Africa, partner HIVST distribution ranked highest (78% probability); in North America, Asia, and the Pacific regions, web-based distribution ranked highest (93% probability), and facility based distribution ranked second in all settings. Across HIVST distribution strategies HIV positivity and linkage was similar to standard testing. Conclusions A range of HIVST distribution strategies are effective in increasing HIV testing. HIVST distribution by sexual partners, web-based distribution, as well as health facility distribution strategies should be considered for implementation to expand the reach of HIV testing services.
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Affiliation(s)
| | - Muhammad S Jamil
- Global HIV, Hepatitis and STI Programme, World Health Organization, Geneva, Switzerland
| | - T Charles Witzel
- Department of Public Health, Environments and Society, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - David V Glidded
- Department of Epidemiology, University of California, San Francisco, California, USA
| | - Cheryl Johnson
- Global HIV, Hepatitis and STI Programme, World Health Organization, Geneva, Switzerland
| | - Noelle Le Trouneau
- Department of Epidemiology, University of California, San Francisco, California, USA
| | - Nathan Ford
- Global HIV, Hepatitis and STI Programme, World Health Organization, Geneva, Switzerland
| | - Kathleen McGee
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Chris Kemp
- Department of Epidemiology, University of California, San Francisco, California, USA
| | - Stefan Baral
- Department of Epidemiology, John Hopkins School of Public Health, Baltimore, Maryland, USA
| | - Sheree Schwartz
- Department of Epidemiology, John Hopkins School of Public Health, Baltimore, Maryland, USA
| | - Elvin H Geng
- Washington University School of Medicine, St Louis, Missouri, USA
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Mody A, Sikombe K, Beres LK, Simbeza S, Mukamba N, Eshun-Wilson I, Schwartz S, Pry J, Padian N, Holmes CB, Bolton-Moore C, Sikazwe I, Geng EH. Profiles of HIV Care Disruptions Among Adult Patients Lost to Follow-up in Zambia: A Latent Class Analysis. J Acquir Immune Defic Syndr 2021; 86:62-72. [PMID: 33105396 PMCID: PMC7722465 DOI: 10.1097/qai.0000000000002530] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 09/28/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Patients report varied barriers to HIV care across multiple domains, but specific barrier patterns may be driven by underlying, but unobserved, behavioral profiles. METHODS We traced a probability sample of patients lost to follow-up (>90 days late) as of July 31, 2015 from 64 clinics in Zambia. Among those found alive, we ascertained patient-reported reasons for care disruptions. We performed latent class analysis to identify patient subgroups with similar patterns of reasons reported and assessed the association between class membership and care status (ie, disengaged versus silently transferred to a new site). RESULTS Among 547 patients, we identified 5 profiles of care disruptions: (1) "Livelihood and Mobility" (30.6% of the population) reported work/school obligations and mobility/travel as reasons for care disruptions; (2) "Clinic Accessibility" (28.9%) reported challenges with attending clinic; (3) "Mobility and Family" (21.9%) reported family obligations, mobility/travel, and transport-related reasons; (4) "Doubting Need for HIV care" (10.2%) reported uncertainty around HIV status or need for clinical care, and (5) "Multidimensional Barriers to Care" (8.3%) reported numerous (mean 5.6) reasons across multiple domains. Patient profiles were significantly associated with care status. The "Doubting Need for HIV Care" class were mostly disengaged (97.9%), followed by the "Multidimensional Barriers to Care" (62.8%), "Clinic Accessibility" (62.4%), "Livelihood and Mobility" (43.6%), and "Mobility and Family" (23.5%) classes. CONCLUSION There are distinct HIV care disruption profiles that are strongly associated with patients' current engagement status. Interventions targeting these unique profiles may enable more effective and tailored strategies for improving HIV treatment outcomes.
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Affiliation(s)
- Aaloke Mody
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO
| | - Kombatende Sikombe
- Centre for Infectious Diseases Research in Zambia, Lusaka, Zambia
- Department of Public Health Environments and Society, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Laura K. Beres
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | - Sandra Simbeza
- Centre for Infectious Diseases Research in Zambia, Lusaka, Zambia
| | - Njekwa Mukamba
- Centre for Infectious Diseases Research in Zambia, Lusaka, Zambia
| | - Ingrid Eshun-Wilson
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO
| | - Sheree Schwartz
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | - Jake Pry
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO
- Centre for Infectious Diseases Research in Zambia, Lusaka, Zambia
| | - Nancy Padian
- Division of Epidemiology, University of California, Berkeley, Berkeley, CA
| | | | - Carolyn Bolton-Moore
- Centre for Infectious Diseases Research in Zambia, Lusaka, Zambia
- Division of Infectious Diseases, University of Alabama, Birmingham, AL
| | - Izukanji Sikazwe
- Centre for Infectious Diseases Research in Zambia, Lusaka, Zambia
| | - Elvin H. Geng
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO
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Mody A, Glidden DV, Eshun-Wilson I, Sikombe K, Simbeza S, Mukamba N, Somwe P, Beres LK, Pry J, Bolton-Moore C, Padian N, Holmes CB, Sikazwe I, Geng EH. Longitudinal Care Cascade Outcomes Among People Eligible for Antiretroviral Therapy Who Are Newly Linking to Care in Zambia: A Multistate Analysis. Clin Infect Dis 2020; 71:e561-e570. [PMID: 32173743 PMCID: PMC7744998 DOI: 10.1093/cid/ciaa268] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 03/13/2020] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Retention in human immunodeficiency virus (HIV) care is dynamic, with patients frequently transitioning in and out of care. Analytical approaches (eg, survival analyses) commonly used to assess HIV care cascade outcomes fail to capture such transitions and therefore incompletely represent care outcomes over time. METHODS We analyzed antiretroviral therapy (ART)-eligible adults newly linking to care at 64 clinics in Zambia between 1 April 2014 and 31 July 2015. We used electronic medical record data and supplemented these with updated care outcomes ascertained by tracing a multistage random sample of patients lost to follow-up (LTFU, >90 days late for last appointment). We performed multistate analyses, incorporating weights from sampling, to estimate the prevalence of 9 care states over time since linkage with respect to ART initiation, retention in care, transfers, and mortality. RESULTS In sum, 23 227 patients (58% female; median age 34 years [interquartile range 28-41]) were ART-eligible at enrollment. At 1 year, 75.2% had initiated ART and were in care: 61.8% were continuously retained, 6.1% had reengaged after LTFU, and 7.3% had transferred. Also, 10.1% were LTFU within 7 days of enrollment, and 15.2% were LTFU at 1 year (6.7% prior to ART). One year after LTFU, 51.6% of those LTFU prior to ART remained out of care compared to 30.2% of those LTFU after initiating ART. Overall, 6.9% of patients had died by 1 year with 3.0% dying prior to ART. CONCLUSION Multistate analyses provide more complete assessments of longitudinal HIV cascade outcomes and reveal treatment gaps at distinct timepoints in care that will still need to be addressed even with universal treatment.
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Affiliation(s)
- Aaloke Mody
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, USA
| | - David V Glidden
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, USA
| | - Ingrid Eshun-Wilson
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, USA
| | | | - Sandra Simbeza
- Centre for Infectious Diseases Research in Zambia, Lusaka, Zambia
| | - Njekwa Mukamba
- Centre for Infectious Diseases Research in Zambia, Lusaka, Zambia
| | - Paul Somwe
- Centre for Infectious Diseases Research in Zambia, Lusaka, Zambia
| | - Laura K Beres
- Department of International Health, Johns Hopkins University School of Public Health, Baltimore, Maryland, USA
| | - Jake Pry
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, USA
- Centre for Infectious Diseases Research in Zambia, Lusaka, Zambia
| | - Carolyn Bolton-Moore
- Centre for Infectious Diseases Research in Zambia, Lusaka, Zambia
- Division of Infectious Diseases, University of Alabama, Birmingham, Alabama, USA
| | - Nancy Padian
- Division of Epidemiology, University of California, Berkeley, Berkeley, California, USA
| | - Charles B Holmes
- Department of Medicine, Georgetown University, Washington, D.C., USA
| | - Izukanji Sikazwe
- Centre for Infectious Diseases Research in Zambia, Lusaka, Zambia
| | - Elvin H Geng
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, USA
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Witzel TC, Eshun-Wilson I, Jamil MS, Tilouche N, Figueroa C, Johnson CC, Reid D, Baggaley R, Siegfried N, Burns FM, Rodger AJ, Weatherburn P. Comparing the effects of HIV self-testing to standard HIV testing for key populations: a systematic review and meta-analysis. BMC Med 2020; 18:381. [PMID: 33267890 PMCID: PMC7713313 DOI: 10.1186/s12916-020-01835-z] [Citation(s) in RCA: 93] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 10/30/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND We update a previous systematic review to inform new World Health Organization HIV self-testing (HIVST) recommendations. We compared the effects of HIVST to standard HIV testing services to understand which service delivery models are effective for key populations. METHODS We did a systematic review of randomised controlled trials (RCTs) which compared HIVST to standard HIV testing in key populations, published from 1 January 2006 to 4 June 2019 in PubMed, Embase, Global Index Medicus, Social Policy and Practice, PsycINFO, Health Management Information Consortium, EBSCO CINAHL Plus, Cochrane Library and Web of Science. We extracted study characteristic and outcome data and conducted risk of bias assessments using the Cochrane ROB tool version 1. Random effects meta-analyses were conducted, and pooled effect estimates were assessed along with other evidence characteristics to determine the overall strength of the evidence using GRADE methodology. RESULTS After screening 5909 titles and abstracts, we identified 10 RCTs which reported on testing outcomes. These included 9679 participants, of whom 5486 were men who have sex with men (MSM), 72 were trans people and 4121 were female sex workers. Service delivery models included facility-based, online/mail and peer distribution. Support components were highly diverse and ranged from helplines to training and supervision. HIVST increased testing uptake by 1.45 times (RR=1.45 95% CI 1.20, 1.75). For MSM and small numbers of trans people, HIVST increased the mean number of HIV tests by 2.56 over follow-up (mean difference = 2.56; 95% CI 1.24, 3.88). There was no difference between HIVST and SoC in regard to positivity among tested overall (RR = 0.91; 95% CI 0.73, 1.15); in sensitivity analysis of positivity among randomised HIVST identified significantly more HIV infections among MSM and trans people (RR = 2.21; 95% CI 1.20, 4.08) and in online/mail distribution systems (RR = 2.21; 95% CI 1.14, 4.32). Yield of positive results in FSW was not significantly different between HIVST and SoC. HIVST reduced linkage to care by 17% compared to SoC overall (RR = 0.83; 95% CI 0.74, 0.92). Impacts on STI testing were mixed; two RCTs showed no decreases in STI testing while one showed significantly lower STI testing in the intervention arm. There were no negative impacts on condom use (RR = 0.95; 95% CI 0.83, 1.08), and social harm was very rare. CONCLUSIONS HIVST is safe and increases testing uptake and frequency as well as yield of positive results for MSM and trans people without negative effects on linkage to HIV care, STI testing, condom use or social harm. Testing uptake was increased for FSW, yield of positive results were not and linkage to HIV care was worse. Strategies to improve linkage to care outcomes for both groups are crucial for effective roll-out.
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Affiliation(s)
- T Charles Witzel
- Department of Public Health, Environments and Society, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK.
| | | | - Muhammad S Jamil
- Global HIV, Hepatitis and STI Programme, World Health Organization, Geneva, Switzerland
| | - Nerissa Tilouche
- Department of Public Health, Environments and Society, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK
| | - Carmen Figueroa
- Global HIV, Hepatitis and STI Programme, World Health Organization, Geneva, Switzerland
| | - Cheryl C Johnson
- Global HIV, Hepatitis and STI Programme, World Health Organization, Geneva, Switzerland
| | - David Reid
- Department of Public Health, Environments and Society, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK
| | - Rachel Baggaley
- Global HIV, Hepatitis and STI Programme, World Health Organization, Geneva, Switzerland
| | - Nandi Siegfried
- Independent Clinical Epidemiologist, Cape Town, Republic of South Africa
| | - Fiona M Burns
- Institute for Global Health, University College London, London, UK
| | - Alison J Rodger
- Institute for Global Health, University College London, London, UK
| | - Peter Weatherburn
- Department of Public Health, Environments and Society, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK
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Conte M, Eshun-Wilson I, Geng E, Imbert E, Hickey MD, Havlir D, Gandhi M, Clemenzi-Allen A. Brief Report: Understanding Preferences for HIV Care Among Patients Experiencing Homelessness or Unstable Housing: A Discrete Choice Experiment. J Acquir Immune Defic Syndr 2020; 85:444-449. [PMID: 33136742 PMCID: PMC8028840 DOI: 10.1097/qai.0000000000002476] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Homelessness and unstable housing (HUH) negatively impact care outcomes for people living with HIV (PLWH). To inform the design of a clinic program for PLWH experiencing HUH, we quantified patient preferences and trade-offs across multiple HIV-service domains using a discrete choice experiment (DCE). METHODS We sequentially sampled PLWH experiencing HUH presenting at an urban HIV clinic with ≥1 missed primary care visit and viremia in the last year to conduct a DCE. Participants chose between 2 hypothetical clinics varying across 5 service attributes: care team "get to know me as a person" versus not; receiving $10, $15, or $20 gift cards for clinic visits; drop-in versus scheduled visits; direct phone communication to care team versus front-desk staff; and staying 2 versus 20 blocks from the clinic. We estimated attribute relative utility (ie, preference) using mixed-effects logistic regression and calculated the monetary trade-off of preferred options. RESULTS Among 65 individuals interviewed, 61% were >40 years old, 45% White, 77% men, 25% heterosexual, 56% lived outdoors/emergency housing, and 44% in temporary housing. Strongest preferences were for patient-centered care team [β = 3.80; 95% confidence interval (CI): 2.57 to 5.02] and drop-in clinic appointments (β = 1.33; 95% CI: 0.85 to 1.80), with a willingness to trade $32.79 (95% CI: 14.75 to 50.81) and $11.45 (95% CI: 2.95 to 19.95) in gift cards/visit, respectively. CONCLUSIONS In this DCE, PLWH experiencing HUH were willing to trade significant financial gain to have a personal relationship with and drop-in access to their care team rather than more resource-intensive services. These findings informed Ward 86's "POP-UP" program for PLWH-HUH and can inform "ending the HIV epidemic" efforts.
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Affiliation(s)
- Madellena Conte
- Division of HIV, ID and Global Medicine, University of California, San Francisco, San Francisco, CA
- Institute of Global Health Sciences, University of California, San Francisco, San Francisco, CA
- Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Ingrid Eshun-Wilson
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO; and
| | - Elvin Geng
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO; and
| | - Elizabeth Imbert
- Division of HIV, ID and Global Medicine, University of California, San Francisco, San Francisco, CA
| | - Matthew D Hickey
- Division of HIV, ID and Global Medicine, University of California, San Francisco, San Francisco, CA
| | - Diane Havlir
- Division of HIV, ID and Global Medicine, University of California, San Francisco, San Francisco, CA
| | - Monica Gandhi
- Division of HIV, ID and Global Medicine, University of California, San Francisco, San Francisco, CA
| | - Angelo Clemenzi-Allen
- Division of HIV, ID and Global Medicine, University of California, San Francisco, San Francisco, CA
- San Francisco Department of Public Health, San Francisco, CA
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Sikombe K, Mody A, Kadota J, Pry J“J, Simbeza S, Eshun-Wilson I, Situmbeko SR, Bukankala C, Beres L, Mukamba N, Wa Mwanza M, Bolton- Moore C, Holmes CB, Geng EH, Sikazwe I. Understanding patient transfers across multiple clinics in Zambia among HIV infected adults. PLoS One 2020; 15:e0241477. [PMID: 33147250 PMCID: PMC7641414 DOI: 10.1371/journal.pone.0241477] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 10/15/2020] [Indexed: 12/30/2022] Open
Abstract
Many patients in HIV care in Africa considered lost to follow up (LTFU) at one facility are reportedly accessing care in another. The success of these unofficial transfers as measured by time to re-entry at the new-facility, prevalence of treatment interruptions, speed of ART-initiation, and overall continuity of care is not well characterized but may reveal opportunities for improvement. We traced a random sample of LTFU HIV-infected patients in Zambia. Among those found alive and reported in care at a new-facility, we reviewed records at the receiving facility to verify transfer; and when verified, documented the transfer experience. We used Kaplan-Meier methods to examine incidence of ART-initiation after transfer to new clinic. We assessed demographic and clinical characteristics, official and cross-provincial transfer for associations with HIV treatment re-engagement using Poisson regression models and associations between official-transfer and same-day ART initiation at the new-facility. Among 350 LTFU-patients, 178 (51%) were successfully verified through chart review at the new-facility. 132 (74.2%) were female, 72 (40.4%) aged 25-35, and 51% were ever recorded as previously being on ART. 110 patients (61.8%) were registered under new ART-IDs and 97 (54.5%) received a new HIV test. 54% of those previously on ART-initiated on the same-day. Using the same ART-ID was associated with same-day initiation compared to those receiving a new ART-ID (p = 0.07). 80% (n = 91) of those ever on ART had evidence of medication initiation at new clinic. Among these, initiation reached 66% (95% CI: 56-75) by 30 days, 77.5% (95% CI: 68-86) by 90 days after new-facility presentation. Many patients use new identifiers at new facilities, indicative of inefficiencies. Re-entry into new facilities among the unofficial-transfer population is often delayed and timely treatment initiation is inconsistent, suggesting interruptions in treatment. Health systems innovations to ensure smooth and safe transfers are needed to maintain quality HIV care.
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Affiliation(s)
- Kombatende Sikombe
- Research Department, Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- Department of Public Health, Environments and Society, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Aaloke Mody
- Division of Infectious Diseases, Washington University School of Medicine, Washington University in St. Louis, St. Louis, Missouri, United States of America
| | - Jillian Kadota
- Division of Pulmonary and Critical Care Medicine and Center for Tuberculosis, University of California San Francisco, San Francisco, California, United States of America
| | - Jesse “Jake” Pry
- Research Department, Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- Division of Infectious Diseases, Washington University School of Medicine, Washington University in St. Louis, St. Louis, Missouri, United States of America
| | - Sandra Simbeza
- Research Department, Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Ingrid Eshun-Wilson
- Division of Infectious Diseases, Washington University School of Medicine, Washington University in St. Louis, St. Louis, Missouri, United States of America
| | | | - Chama Bukankala
- Research Department, Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Laura Beres
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Njekwa Mukamba
- Research Department, Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Mwanza Wa Mwanza
- Research Department, Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Carolyn Bolton- Moore
- Research Department, Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- Division of Infectious Diseases, University of Alabama, Birmingham, Alabama, United States of America
| | - Charles B. Holmes
- Research Department, Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- Center for Global Health and Quality, Georgetown University, Washington, District of Columbia, United States of America
| | - Elvin H. Geng
- Division of Infectious Diseases, Washington University School of Medicine, Washington University in St. Louis, St. Louis, Missouri, United States of America
| | - Izukanji Sikazwe
- Research Department, Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
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Eshun-Wilson I, Kim HY, Schwartz S, Conte M, Glidden DV, Geng EH. Exploring Relative Preferences for HIV Service Features Using Discrete Choice Experiments: a Synthetic Review. Curr HIV/AIDS Rep 2020; 17:467-477. [PMID: 32860150 PMCID: PMC7497362 DOI: 10.1007/s11904-020-00520-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
PURPOSE OF REVIEW Aligning HIV treatment services with patient preferences can promote long-term engagement. A rising number of studies solicit such preferences using discrete choice experiments, but have not been systematically reviewed to seek generalizable insights. Using a systematic search, we identified eleven choice experiments evaluating preferences for HIV treatment services published between 2004 and 2020. RECENT FINDINGS Across settings, the strongest preference was for nice, patient-centered providers, for which participants were willing to trade considerable amounts of time, money, and travel distance. In low- and middle-income countries, participants also preferred collecting antiretroviral therapy (ART) less frequently than 1 monthly, but showed no strong preference for 3-compared with 6-month refill frequency. Facility waiting times and travel distances were also important but were frequently outranked by stronger preferences. Health facility-based services were preferred to community- or home-based services, but this preference varied by setting. In high-income countries, the availability of unscheduled appointments was highly valued. Stigma was rarely explored and costs were a ubiquitous driver of preferences. While present improvement efforts have focused on designs to enhance access (reduced waiting time, travel distance, and ART refill frequency), few initiatives focus on the patient-provider interaction, which represents a promising critical area for inquiry and investment. If HIV programs hope to truly deliver patient-centered care, they will need to incorporate patient preferences into service delivery strategies. Discrete choice experiments can not only inform such strategies but also contribute to prioritization efforts for policy-making decisions.
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Affiliation(s)
- I Eshun-Wilson
- Division of Infectious Disease, School of Medicine, Washington University in St. Louis, Childrens Pl, St. Louis, MO, 63110, USA.
| | - H-Y Kim
- Department of Population Health, New York University School of Medicine, New York, USA
| | - S Schwartz
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - M Conte
- Zucker School of Medicine at Hofstra/Northwell in Hempstead, New York, USA
| | - D V Glidden
- Department of Epidemiology, University of California, San Francisco, USA
| | - E H Geng
- Division of Infectious Disease, School of Medicine, Washington University in St. Louis, Childrens Pl, St. Louis, MO, 63110, USA
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Grimsrud A, Wilkinson L, Eshun-Wilson I, Holmes C, Sikazwe I, Katz IT. Understanding Engagement in HIV Programmes: How Health Services Can Adapt to Ensure No One Is Left Behind. Curr HIV/AIDS Rep 2020; 17:458-466. [PMID: 32844274 PMCID: PMC7497373 DOI: 10.1007/s11904-020-00522-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
PURPOSE OF REVIEW Despite the significant progress in the HIV response, gaps remain in ensuring engagement in care to support life-long medication adherence and viral suppression. This review sought to describe the different points in the HIV care cascade where people living with HIV were not engaging and highlight promising interventions. RECENT FINDINGS There are opportunities to improve engagement both between testing and treatment and to support re-engagement in care for those in a treatment interruption. The gap between testing and treatment includes people who know their HIV status and people who do not know their status. People in a treatment interruption include those who interrupt immediately following initiation, early on in their treatment (first 6 months) and late (after 6 months or more on ART). For each of these groups, specific interventions are required to support improved engagement. There are diverse needs and specific populations of people living with HIV who are not engaged in care, and differentiated service delivery interventions are required to meet their needs and expectations. For the HIV response to realise the 2030 targets, engagement will need to be supported by quality care and patient choice combined with empowered patients who are treatment literate and have been supported to improve self-management.
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Affiliation(s)
- Anna Grimsrud
- International AIDS Society, 3 Doris Road, Claremont, Cape Town, 7708 South Africa
- Desmond Tutu HIV Centre, University of Cape Town, Anzio Road, Observatory, Cape Town, 7925 South Africa
| | - Lynne Wilkinson
- International AIDS Society, 3 Doris Road, Claremont, Cape Town, 7708 South Africa
- Department of Public Health Medicine, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Charles Holmes
- Center for Innovation in Global Health, Georgetown University, Washington, DC USA
| | - Izukanji Sikazwe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Ingrid T. Katz
- Department of Medicine, Brigham and Women’s Hospital, Boston, MA USA
- Harvard Medical School, Boston, MA USA
- Massachusetts General Hospital Center for Global Health, Boston, MA USA
- Harvard Global Health Institute, Cambridge, MA USA
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Kerkhoff AD, Sikombe K, Eshun-Wilson I, Sikazwe I, Glidden DV, Pry JM, Somwe P, Beres LK, Simbeza S, Mwamba C, Bukankala C, Hantuba C, Moore CB, Holmes CB, Padian N, Geng EH. Mortality estimates by age and sex among persons living with HIV after ART initiation in Zambia using electronic medical records supplemented with tracing a sample of lost patients: A cohort study. PLoS Med 2020; 17:e1003107. [PMID: 32401797 PMCID: PMC7219718 DOI: 10.1371/journal.pmed.1003107] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 04/10/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Men in sub-Saharan Africa have lower engagement and retention in HIV services compared to women, which may result in differential survival. However, the true magnitude of difference in HIV-related mortality between men and women receiving antiretroviral therapy (ART) is incompletely characterized. METHODS AND FINDINGS We evaluated HIV-positive adults ≥18 years old newly initiating ART in 4 Zambian provinces (Eastern, Lusaka, Southern, and Western). In addition to mortality data obtained from routine electronic medical records, we intensively traced a random sample of patients lost to follow-up (LTFU) and incorporated tracing outcomes through inverse probability weights. Sex-specific mortality rates and rate differences were determined using Poisson regression. Parametric g-computation was used to estimate adjusted mortality rates by sex and age. The study included 49,129 adults newly initiated on ART between August 2013 and July 2015; overall, the median age among patients was 35 years, the median baseline CD4 count was 262 cells/μl, and 37.2% were men. Men comprised a smaller proportion of individuals starting ART (37.2% versus 62.8%), tended to be older (median age 37 versus 33 years), and tended to have lower CD4 counts (median 220 versus 289 cells/μl) at the time of ART initiation compared to women. The overall rate of mortality among men was 10.3 (95% CI 8.2-12.4) deaths/100 person-years (PYs), compared to 5.5 (95% CI 4.3-6.8) deaths/100 PYs among women (difference +4.7 [95% CI 2.3-7.2] deaths/100 PYs; p < 0.001). Compared to women in the same age groups, men's mortality rates were particularly elevated among those <30 years old (+6.7 deaths/100 PYs difference), those attending rural health centers (+9.4 deaths/100 PYs difference), those who had an initial CD4 count < 100 cells/μl (+9.2 deaths/100 PYs difference), and those who were unmarried (+8.0 deaths/100 PYs difference). After adjustment for potential confounders and mediators including CD4 count, a substantially higher mortality rate was predicted among men <30 years old compared to women of the same age, while women ≥50 years old had a mortality rate similar to that of age-matched men, but considerably higher than that predicted among young women (<30 years old). No clinically significant differences were evident with respect to rates of facility transfer or care disengagement between men and women. The main study limitations were the inability to successfully ascertain outcomes in all patients selected for tracing and missing clinical and laboratory data due to the use of medical records. CONCLUSIONS In this study, we found that among HIV-positive adults newly initiating ART, mortality among men exceeded mortality among women; disparities were most pronounced among young patients. Older women, however, also experienced high mortality. Specific interventions for men and older women at highest mortality risk are needed to improve HIV treatment outcomes.
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Affiliation(s)
- Andrew D. Kerkhoff
- Division of HIV, Infectious Diseases and Global Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, San Francisco, California, United States of America
| | | | - Ingrid Eshun-Wilson
- Division of Infectious Diseases, Department of Medicine, Washington University, St. Louis, Missouri, United States of America
- Center for Dissemination and Implementation, Institute for Public Health, Washington University, St. Louis, Missouri, United States of America
| | - Izukanji Sikazwe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - David V. Glidden
- Division of HIV, Infectious Diseases and Global Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, San Francisco, California, United States of America
| | - Jake M. Pry
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- Division of Infectious Diseases, Department of Medicine, Washington University, St. Louis, Missouri, United States of America
- Center for Dissemination and Implementation, Institute for Public Health, Washington University, St. Louis, Missouri, United States of America
| | - Paul Somwe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Laura K. Beres
- Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Sandra Simbeza
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Chanda Mwamba
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Chama Bukankala
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Cardinal Hantuba
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Carolyn Bolton Moore
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Charles B. Holmes
- Center for Dissemination and Implementation, Institute for Public Health, Washington University, St. Louis, Missouri, United States of America
- Georgetown University, Washington, District of Columbia, United States of America
| | - Nancy Padian
- University of California, Berkeley, Berkeley, California, United States of America
| | - Elvin H. Geng
- Division of Infectious Diseases, Department of Medicine, Washington University, St. Louis, Missouri, United States of America
- Center for Dissemination and Implementation, Institute for Public Health, Washington University, St. Louis, Missouri, United States of America
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Peluso MJ, Eshun-Wilson I, Henrich TJ, Chin-Hong P. 324. Outcomes of Immunomodulatory and Biologic Therapy in People Living with HIV: A Report from Two Academic Hospitals. Open Forum Infect Dis 2019. [PMCID: PMC6810662 DOI: 10.1093/ofid/ofz360.397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background The use of immunomodulatory drugs (IMDs) is increasingly common. However, data on outcomes of IMD use in people living with HIV (PLWH) are limited and may be biased due to selective reporting of certain outcomes. Institution-level data reflecting patient-time at risk have not been described. Methods We systematically identified all PLWH prescribed non-steroidal IMDs from 2012 to 2019 at two centers. We defined a treatment episode (TE) as an uninterrupted period on a particular IMD regimen. Patients contributed multiple TEs if interrupting or switching therapy. We excluded those with lymphoproliferative disorders or transplants. We quantified infections and blips, defined as a detectable viral load following an undetectable result. Results 35 patients contributed 55 TEs comprising 24,020 patient-days at risk. 29/35 (83%) were male, median age was 53 (IQR 39–59), median CD4 nadir was 197 (IQR 100–314), and 12/35 (34%) had a prior opportunistic infection. TEs utilized TNF inhibitors (19/55, 35%), PD-1 inhibitors (11/55, 20%), antimetabolites (7/55, 13%), interleukin inhibitors (7/55, 13%), and other agents (7/55, 13%). 4/55 (7%) involved in dual therapy. 32/35 (94%) patients were on antiretroviral therapy (ART) at IMD initiation; one was off therapy, one already on IMDs-acquired HIV, and one was an elite controller. Median CD4 count was 472 (IQR 337–807); CD4 was < 500 in 28/55 TEs (51%). Preceding plasma HIV RNA was undetectable in 36/55 (65%) TEs. Of these, 18 (50%) were associated with a viral blip within 1 year; one blip was >200 copies and none resulted in sustained viremia. Compared with other agents, PD-1 inhibitors were associated with a higher blip rate (incidence rate ratio 4.3, 1.3–12.3). 17/55 (32%) TEs were initiated with detectable plasma HIV RNA, which declined on ART in 13/15 (87%) TEs with follow-up testing; one patient stopped ART and one later suppressed. 9/55 (16%) TEs involved an infectious complication (7 soft-tissue infections, 2 pneumonias), although none was clearly attributed to IMDs. 36/55 (65%) TEs had good therapeutic response. Conclusion IMDs can be used without major complications in PLWH on ART, including those not yet suppressed or with CD4 counts < 500. PD-1 inhibitors may be associated with a higher rate of viral blips, although the clinical significance is unclear. Disclosures All authors: No reported disclosures.
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Affiliation(s)
- Michael J Peluso
- University of California, San Francisco, San Francisco, California
| | | | | | - Peter Chin-Hong
- University of California, San Francisco, San Francisco, California
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Mody A, Eshun-Wilson I, Sikombe K, Schwartz SR, Beres LK, Simbeza S, Mukamba N, Somwe P, Bolton-Moore C, Padian N, Holmes CB, Sikazwe I, Geng EH. Longitudinal engagement trajectories and risk of death among new ART starters in Zambia: A group-based multi-trajectory analysis. PLoS Med 2019; 16:e1002959. [PMID: 31661487 PMCID: PMC6818762 DOI: 10.1371/journal.pmed.1002959] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Accepted: 10/07/2019] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Retention in HIV treatment must be improved to advance the HIV response, but research to characterize gaps in retention has focused on estimates from single time points and population-level averages. These approaches do not assess the engagement patterns of individual patients over time and fail to account for both their dynamic nature and the heterogeneity between patients. We apply group-based trajectory analysis-a special application of latent class analysis to longitudinal data-among new antiretroviral therapy (ART) starters in Zambia to identify groups defined by engagement patterns over time and to assess their association with mortality. METHODS AND FINDINGS We analyzed a cohort of HIV-infected adults who newly started ART between August 1, 2013, and February 1, 2015, across 64 clinics in Zambia. We performed group-based multi-trajectory analysis to identify subgroups with distinct trajectories in medication possession ratio (MPR, a validated adherence metric based on pharmacy refill data) over the past 3 months and loss to follow-up (LTFU, >90 days late for last visit) among patients with at least 180 days of observation time. We used multinomial logistic regression to identify baseline factors associated with belonging to particular trajectory groups. We obtained Kaplan-Meier estimates with bootstrapped confidence intervals of the cumulative incidence of mortality stratified by trajectory group and performed adjusted Poisson regression to estimate adjusted incidence rate ratios (aIRRs) for mortality by trajectory group. Inverse probability weights were applied to all analyses to account for updated outcomes ascertained from tracing a random subset of patients lost to follow-up as of July 31, 2015. Overall, 38,879 patients (63.3% female, median age 35 years [IQR 29-41], median enrollment CD4 count 280 cells/μl [IQR 146-431]) were included in our cohort. Analyses revealed 6 trajectory groups among the new ART starters: (1) 28.5% of patients demonstrated consistently high adherence and retention; (2) 22.2% showed early nonadherence but consistent retention; (3) 21.6% showed gradually decreasing adherence and retention; (4) 8.6% showed early LTFU with later reengagement; (5) 8.7% had early LTFU without reengagement; and (6) 10.4% had late LTFU without reengagement. Identified groups exhibited large differences in survival: after adjustment, the "early LTFU with reengagement" group (aIRR 3.4 [95% CI 1.2-9.7], p = 0.019), the "early LTFU" group (aIRR 6.4 [95% CI 2.5-16.3], p < 0.001), and the "late LTFU" group (aIRR 4.7 [95% CI 2.0-11.3], p = 0.001) had higher rates of mortality as compared to the group with consistently high adherence/retention. Limitations of this study include using data observed after baseline to identify trajectory groups and to classify patients into these groups, excluding patients who died or transferred within the first 180 days, and the uncertain generalizability of the data to current care standards. CONCLUSIONS Among new ART starters in Zambia, we observed 6 patient subgroups that demonstrated distinctive engagement trajectories over time and that were associated with marked differences in the subsequent risk of mortality. Further efforts to develop tailored intervention strategies for different types of engagement behaviors, monitor early engagement to identify higher-risk patients, and better understand the determinants of these heterogeneous behaviors can help improve care delivery and survival in this population.
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Affiliation(s)
- Aaloke Mody
- Division of HIV, ID and Global Medicine, University of California, San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, California, United States of America
- * E-mail:
| | - Ingrid Eshun-Wilson
- Division of HIV, ID and Global Medicine, University of California, San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, California, United States of America
| | | | - Sheree R. Schwartz
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Laura K. Beres
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Sandra Simbeza
- Centre for Infectious Diseases Research in Zambia, Lusaka, Zambia
| | - Njekwa Mukamba
- Centre for Infectious Diseases Research in Zambia, Lusaka, Zambia
| | - Paul Somwe
- Centre for Infectious Diseases Research in Zambia, Lusaka, Zambia
| | - Carolyn Bolton-Moore
- Centre for Infectious Diseases Research in Zambia, Lusaka, Zambia
- Division of Infectious Diseases, University of Alabama at Birmingham, Alabama, United States of America
| | - Nancy Padian
- Division of Epidemiology, University of California, Berkeley, California, United States of America
| | - Charles B. Holmes
- Department of Medicine, Georgetown University, Washington, District of Columbia, United States of America
| | - Izukanji Sikazwe
- Centre for Infectious Diseases Research in Zambia, Lusaka, Zambia
| | - Elvin H. Geng
- Division of HIV, ID and Global Medicine, University of California, San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, California, United States of America
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Sikazwe I, Eshun-Wilson I, Sikombe K, Czaicki N, Somwe P, Mody A, Simbeza S, Glidden DV, Chizema E, Mulenga LB, Padian N, Duncombe CJ, Bolton-Moore C, Beres LK, Holmes CB, Geng E. Correction: Retention and viral suppression in a cohort of HIV patients on antiretroviral therapy in Zambia: Regionally representative estimates using a multistage-sampling-based approach. PLoS Med 2019; 16:e1002918. [PMID: 31469847 PMCID: PMC6716623 DOI: 10.1371/journal.pmed.1002918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
[This corrects the article DOI: 10.1371/journal.pmed.1002811.].
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Abstract
BACKGROUND Despite antiretroviral therapy (ART) being widely available, HIV continues to cause substantial illness and premature death in low-and-middle-income countries. High rates of loss to follow-up after HIV diagnosis can delay people starting ART. Starting ART within seven days of HIV diagnosis (rapid ART initiation) could reduce loss to follow-up, improve virological suppression rates, and reduce mortality. OBJECTIVES To assess the effects of interventions for rapid initiation of ART (defined as offering ART within seven days of HIV diagnosis) on treatment outcomes and mortality in people living with HIV. We also aimed to describe the characteristics of rapid ART interventions used in the included studies. SEARCH METHODS We searched CENTRAL, the Cochrane Database of Systematic Reviews, MEDLINE, Embase, and four other databases up to 14 August 2018. There was no restriction on date, language, or publication status. We also searched ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform, and websites for unpublished literature, including conference abstracts. SELECTION CRITERIA We included randomized controlled trials (RCTs) that compared rapid ART versus standard care in people living with HIV. Children, adults, and adolescents from any setting were eligible for inclusion. DATA COLLECTION AND ANALYSIS Two review authors independently assessed the eligibility of the studies identified in the search, assessed the risk of bias and extracted data. The primary outcomes were mortality and virological suppression at 12 months. We have presented all outcomes using risk ratios (RR), with 95% confidence intervals (CIs). Where appropriate, we pooled the results in meta-analysis. We assessed the certainty of the evidence using the GRADE approach. MAIN RESULTS We included seven studies with 18,011 participants in the review. All studies were carried out in low- and middle-income countries in adults aged 18 years old or older. Only one study included pregnant women.In all the studies, the rapid ART intervention was offered as part of a package that included several cointerventions targeting individuals, health workers and health system processes delivered alongside rapid ART that aimed to facilitate uptake and adherence to ART.Comparing rapid ART with standard initiation probably results in greater viral suppression at 12 months (RR 1.18, 95% CI 1.10 to 1.27; 2719 participants, 4 studies; moderate-certainty evidence) and better ART uptake at 12 months (RR 1.09, 95% CI 1.06 to 1.12; 3713 participants, 4 studies; moderate-certainty evidence), and may improve retention in care at 12 months (RR 1.22, 95% CI 1.11 to 1.35; 5001 participants, 6 studies; low-certainty evidence). Rapid ART initiation was associated with a lower mortality estimate, however the CIs included no effect when compared to standard of care (RR 0.72, 95% CI 0.51 to 1.01; 5451 participants, 7 studies; very low-certainty evidence). It is uncertain whether rapid ART has an effect on modification of ART treatment regimens as data are lacking (RR 7.89, 95% CI 0.76 to 81.74; 977 participants, 2 studies; very low-certainty evidence). There was insufficient evidence to draw conclusions on the occurrence of adverse events. AUTHORS' CONCLUSIONS RCTs that include initiation of ART within one week of diagnosis appear to improve outcomes across the HIV treatment cascade in low- and middle-income settings. The studies demonstrating these effects delivered rapid ART combined with several setting-specific cointerventions. This highlights the need for pragmatic research to identify feasible packages that assure the effects seen in the trials when delivered through complex health systems.
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Affiliation(s)
- Alberto Mateo-Urdiales
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK, L3 5QA
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Sikazwe I, Eshun-Wilson I, Sikombe K, Czaicki N, Somwe P, Mody A, Simbeza S, Glidden DV, Chizema E, Mulenga LB, Padian N, Duncombe CJ, Bolton-Moore C, Beres LK, Holmes CB, Geng E. Retention and viral suppression in a cohort of HIV patients on antiretroviral therapy in Zambia: Regionally representative estimates using a multistage-sampling-based approach. PLoS Med 2019; 16:e1002811. [PMID: 31150380 PMCID: PMC6544202 DOI: 10.1371/journal.pmed.1002811] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 04/23/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Although the success of HIV treatment programs depends on retention and viral suppression, routine program monitoring of these outcomes may be incomplete. We used data from the national electronic medical record (EMR) system in Zambia to enumerate a large and regionally representative cohort of patients on treatment. We traced a random sample with unknown outcomes (lost to follow-up) to document true care status and HIV RNA levels. METHODS AND FINDINGS On 31 July 2015, we selected facilities from 4 provinces in 12 joint strata defined by facility type and province with probability proportional to size. In each facility, we enumerated adults with at least 1 clinical encounter after treatment initiation in the previous 24 months. From this cohort, we identified lost-to-follow-up patients (defined as 90 or more days late for their last appointment), selected a random sample, and intensively reviewed their records and traced them via phone calls and in-person visits in the community. In 1 of 4 provinces, we also collected dried blood spots (DBSs) for plasma HIV RNA testing. We used inverse probability weights to incorporate sampling outcomes into Aalen-Johansen and Cox proportional hazards regression to estimate retention and viremia. We used a bias analysis approach to correct for the known inaccuracy of plasma HIV RNA levels obtained from DBSs. From a total of 64 facilities with 165,464 adults on ART, we selected 32 facilities with 104,966 patients, of whom 17,602 (17%) were lost to follow-up: Those lost to follow-up had median age 36 years, 60% were female (N = 11,241), they had median enrollment CD4 count of 220 cells/μl, and 38% had WHO stage 1 clinical disease (N = 10,690). We traced 2,892 (16%) and found updated outcomes for 2,163 (75%): 412 (19%) had died, 836 (39%) were alive and in care at their original clinic, 457 (21%) had transferred to a new clinic, 255 (12%) were alive and out of care, and 203 (9%) were alive but we were unable to determine care status. Estimates using data from the EMR only suggested that 42.7% (95% CI 38.0%-47.1%) of new ART starters and 72.3% (95% CI 71.8%-73.0%) of all ART users were retained at 2 years. After incorporating updated data through tracing, we found that 77.3% (95% CI 70.5%-84.0%) of new initiates and 91.2% (95% CI 90.5%-91.8%) of all ART users were retained (at original clinic or transferred), indicating that routine program data underestimated retention in care markedly. In Lusaka Province, HIV RNA levels greater than or equal to 1,000 copies/ml were present in 18.1% (95% CI 14.0%-22.3%) of patients in care, 71.3% (95% CI 58.2%-84.4%) of lost patients, and 24.7% (95% CI 21.0%-29.3%). The main study limitations were imperfect response rates and the use of self-reported care status. CONCLUSIONS In this region of Zambia, routine program data underestimated retention, and the point prevalence of unsuppressed HIV RNA was high when lost patients were accounted for. Viremia was prevalent among patients who unofficially transferred: Sustained engagement remains a challenge among HIV patients in Zambia, and targeted sampling is an effective strategy to identify such gaps in the care cascade and monitor programmatic progress.
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Affiliation(s)
- Izukanji Sikazwe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- * E-mail:
| | - Ingrid Eshun-Wilson
- University of California, San Francisco, San Francisco, California, United States of America
| | | | - Nancy Czaicki
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- University of California, San Francisco, San Francisco, California, United States of America
| | - Paul Somwe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Aaloke Mody
- University of California, San Francisco, San Francisco, California, United States of America
| | - Sandra Simbeza
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - David V. Glidden
- University of California, San Francisco, San Francisco, California, United States of America
| | | | | | - Nancy Padian
- University of California, Berkeley, Berkeley, California, United States of America
| | - Chris J. Duncombe
- International Association of Providers of AIDS Care, Washington, District of Columbia, United States of America
| | - Carolyn Bolton-Moore
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Laura K. Beres
- Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Charles B. Holmes
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- Johns Hopkins University, Baltimore, Maryland, United States of America
- Georgetown University, Washington, District of Columbia, United States of America
| | - Elvin Geng
- University of California, San Francisco, San Francisco, California, United States of America
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Eshun-Wilson I, Jaffer S, Smith R, Johnson S, Hine P, Mateo A, Stephani AM, Garner P. Maintaining relevance in HIV systematic reviews: an evaluation of Cochrane reviews. Syst Rev 2019; 8:46. [PMID: 30732644 PMCID: PMC6366015 DOI: 10.1186/s13643-019-0960-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Accepted: 01/22/2019] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Research turnover in the HIV field is rapid, and as a result, maintaining high-quality, up-to-date, and relevant systematic reviews is a challenge. One approach is to frequently update published reviews. METHODS We evaluated the methods and relevance of all HIV systematic reviews and protocols published in the Cochrane Library over a 16-year period (2000-2016) to determine the need to update published reviews or complete of reviews in progress. RESULTS Of 148 published reviews and protocols, 129 (87%) were identified as not for updating or progression to publication, mostly due to research questions which were either entirely outdated or addressed questions in an outdated manner (N = 89; 60%); this was anticipated for older reviews, but was found also to be the case for recent publications. Some research questions were also inadequately conceptualized, particularly when complex pragmatic trials or behavioral interventions were included. CONCLUSIONS We suggest that authors clearly characterize interventions and synthesis approaches in their review protocols. In research fields, such as HIV, where questions change frequently, systematic reviews and protocols should be regularly re-evaluated to ensure relevance to current questions. This process of re-evaluation should be incorporated into the methods of living systematic reviews.
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Affiliation(s)
- Ingrid Eshun-Wilson
- Center for Evidence Based Health Care, Division of Epidemiology and Biostatistics, Department of Global Health, Stellenbosch University, Francie Van Zyl drive, Cape Town, 7505, South Africa. .,University of California, San Francisco, USA.
| | - Shahista Jaffer
- Center for Evidence Based Health Care, Division of Epidemiology and Biostatistics, Department of Global Health, Stellenbosch University, Francie Van Zyl drive, Cape Town, 7505, South Africa
| | - Rhodine Smith
- Center for Evidence Based Health Care, Division of Epidemiology and Biostatistics, Department of Global Health, Stellenbosch University, Francie Van Zyl drive, Cape Town, 7505, South Africa
| | - Samuel Johnson
- Cochrane Infectious Diseases Group, Centre for Evidence Synthesis in Global Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Paul Hine
- Cochrane Infectious Diseases Group, Centre for Evidence Synthesis in Global Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Alberto Mateo
- Cochrane Infectious Diseases Group, Centre for Evidence Synthesis in Global Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Anne-Marie Stephani
- Cochrane Infectious Diseases Group, Centre for Evidence Synthesis in Global Health, Liverpool School of Tropical Medicine, Liverpool, UK.,University of Central Lancashire, Lancashire, UK
| | - Paul Garner
- Cochrane Infectious Diseases Group, Centre for Evidence Synthesis in Global Health, Liverpool School of Tropical Medicine, Liverpool, UK
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Eshun-Wilson I, Rohwer A, Hendricks L, Oliver S, Garner P. Being HIV positive and staying on antiretroviral therapy in Africa: A qualitative systematic review and theoretical model. PLoS One 2019; 14:e0210408. [PMID: 30629648 PMCID: PMC6328200 DOI: 10.1371/journal.pone.0210408&type=printable] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 12/21/2018] [Indexed: 05/22/2023] Open
Abstract
BACKGROUND Adherence to antiretroviral therapy (ART) and long-term uninterrupted engagement in HIV care is difficult for HIV-positive people, and randomized trials of specific techniques to promote adherence often show small or negligible effects. Understanding what influences decision-making in HIV-positive people in Africa may help researchers and policy makers in the development of broader, more effective interventions and policies. METHODS We used thematic synthesis and a grounded theory approach to generate a detailed narrative and theoretical model reflecting life with HIV in Africa, and how this influences ART adherence and engagement decisions. We included qualitative primary studies that explored perspectives, perceptions and experiences of HIV-positive people, caregivers and healthcare service providers. We searched databases from 1 January 2013 to 9 December 2016, screened all studies, and selected those for inclusion using purposeful sampling methods. Included studies were coded with Atlas.ti, and we assessed methodological quality across five domains. RESULTS We included 59 studies from Africa in the synthesis. Nine themes emerged which we grouped under three main headings. First, people who are HIV-positive live in a complicated world where they must navigate the challenges presented by poverty, competing priorities, unpredictable life events, social identity, gender norms, stigma, and medical pluralism-these influences can make initiating and maintaining ART difficult. Second, the health system is generally seen as punishing and uninviting and this can drive HIV-positive people out of care. Third, long-term engagement and adherence requires adaptation and incorporation of ART into daily life, a process which is facilitated by: inherent self-efficacy, social responsibilities, previous HIV-related illnesses and emotional, practical or financial support. These factors together can lead to a "tipping point", a point in time when patients choose to either engage or disengage from care. HIV-positive people may cycle in and out of these care states in response to fluctuations in influences over time. CONCLUSION This analysis provides a practical theory, arising from thematic synthesis of research, to help understand the dynamics of adherence to ART and engagement in HIV care. This can contribute to the design of service delivery approaches, and informed thinking and action on the part of policy makers, providers, and society: to understand what it is to be HIV-positive in Africa and how attitudes and the health service need to shift to help those with HIV lead 'normal' lives.
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Affiliation(s)
- Ingrid Eshun-Wilson
- Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Department of Medicine, University of California San Francisco, San Francisco, California, United States of America
- * E-mail:
| | - Anke Rohwer
- Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Lynn Hendricks
- Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Sandy Oliver
- UCL Institute of Education, University College London, London, United Kingdom
- Africa Centre for Evidence, University of Johannesburg, Johannesburg, South Africa
| | - Paul Garner
- Centre for Evidence Synthesis in Global Health, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
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Zanolini A, Sikombe K, Sikazwe I, Eshun-Wilson I, Somwe P, Bolton Moore C, Topp SM, Czaicki N, Beres LK, Mwamba CP, Padian N, Holmes CB, Geng EH. Understanding preferences for HIV care and treatment in Zambia: Evidence from a discrete choice experiment among patients who have been lost to follow-up. PLoS Med 2018; 15:e1002636. [PMID: 30102693 PMCID: PMC6089406 DOI: 10.1371/journal.pmed.1002636] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2018] [Accepted: 07/10/2018] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND In public health HIV treatment programs in Africa, long-term retention remains a challenge. A number of improvement strategies exist (e.g., bring services closer to home, reduce visit frequency, expand hours of clinic operation, improve provider attitude), but implementers lack data about which to prioritize when resource constraints preclude implementing all. We used a discrete choice experiment (DCE) to quantify preferences for a number of potential clinic improvements to enhance retention. METHODS AND FINDINGS We sought a random sample of HIV patients who were lost to follow-up (defined as >90 days late for their last scheduled appointment) from treatment facilities in Lusaka Province, Zambia. Among those contacted, we asked patients to choose between 2 hypothetical clinics in which the following 5 attributes of those facilities were varied: waiting time at the clinic (1, 3, or 5 hours), distance from residence to clinic (5, 10, or 20 km), ART supply given at each refill (1, 3, or 5 months), hours of operation (morning only, morning and afternoon, or morning and Saturday), and staff attitude ("rude" or "nice"). We used mixed-effects logistic regression to estimate relative utility (i.e., preference) for each attribute level. We calculated how much additional waiting time or travel distance patients were willing to accept in order to obtain other desired features of care. Between December 9, 2015 and May 31, 2016, we offered the survey to 385 patients, and 280 participated (average age 35; 60% female). Patients exhibited a strong preference for nice as opposed to rude providers (relative utility of 2.66; 95% CI 1.9-3.42; p < 0.001). In a standard willingness to wait or willingness to travel analysis, patients were willing to wait 19 hours more or travel 45 km farther to see nice rather than rude providers. An alternative analysis, in which trade-offs were constrained to values actually posed to patients in the experiment, suggested that patients were willing to accept a facility located 10 km from home (as opposed to 5) that required 5 hours of waiting per visit (as opposed to 1 hour) and that dispensed 3 months of medications (instead of 5) in order to access nice (as opposed to rude) providers. This study was limited by the fact that attributes included in the experiment may not have captured additional important determinants of preference. CONCLUSIONS In this study, patients were willing to expend considerable time and effort as well as accept substantial inconvenience in order to access providers with a nice attitude. In addition to service delivery redesign (e.g., differentiated service delivery models), current improvement strategies should also prioritize improving provider attitude and promoting patient centeredness-an area of limited policy attention to date.
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Affiliation(s)
- Arianna Zanolini
- United Kingdom Department for International Development, Dar Es Salaam office, Dar Es Salaam, Tanzania
| | | | - Izukanji Sikazwe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Ingrid Eshun-Wilson
- University of California, San Francisco, San Francisco, California, United States of America
| | - Paul Somwe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Carolyn Bolton Moore
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | | | - Nancy Czaicki
- University of California, San Francisco, San Francisco, California, United States of America
| | - Laura K. Beres
- Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Chanda P. Mwamba
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Nancy Padian
- University of California, Berkeley, Berkeley, California, United States of America
| | - Charles B. Holmes
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- Johns Hopkins University, Baltimore, Maryland, United States of America
- Georgetown University, Washington D.C., United States of America
| | - Elvin H. Geng
- University of California, San Francisco, San Francisco, California, United States of America
- * E-mail:
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Mateo-Urdiales A, Johnson S, Nachega JB, Eshun-Wilson I. Rapid initiation of antiretroviral therapy for people living with HIV. Cochrane Database of Systematic Reviews 2018. [DOI: 10.1002/14651858.cd012962] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Alberto Mateo-Urdiales
- Liverpool School of Tropical Medicine; Department of Clinical Sciences; Liverpool UK L3 5QA
| | - Samuel Johnson
- Liverpool School of Tropical Medicine; Department of Clinical Sciences; Liverpool UK L3 5QA
| | - Jean B Nachega
- University of Pittsburgh; Department of Epidemiology, Infectious Diseases and Microbiology; Pittsburgh Pennsylvania USA
- Johns Hopkins Bloomberg School of Public Health; Department of Epidemiology and International Health; Baltimore Maryland USA
- Stellenbosch University; Centre for Infectious Diseases; Cape Town South Africa
| | - Ingrid Eshun-Wilson
- Stellenbosch University; Centre for Evidence Based Health Care, Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences; Francie van Zyl Drive, Tygerberg, 7505, Parow Cape Town Western Cape South Africa 7505
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Holmes CB, Sikazwe I, Sikombe K, Eshun-Wilson I, Czaicki N, Beres LK, Mukamba N, Simbeza S, Bolton Moore C, Hantuba C, Mwaba P, Phiri C, Padian N, Glidden DV, Geng E. Estimated mortality on HIV treatment among active patients and patients lost to follow-up in 4 provinces of Zambia: Findings from a multistage sampling-based survey. PLoS Med 2018; 15:e1002489. [PMID: 29329301 PMCID: PMC5766235 DOI: 10.1371/journal.pmed.1002489] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Accepted: 12/11/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Survival represents the single most important indicator of successful HIV treatment. Routine monitoring fails to capture most deaths. As a result, both regional assessments of the impact of HIV services and identification of hotspots for improvement efforts are limited. We sought to assess true mortality on treatment, characterize the extent under-reporting of mortality in routine health information systems in Zambia, and identify drivers of mortality across sites and over time using a multistage, regionally representative sampling approach. METHODS AND FINDINGS We enumerated all HIV infected adults on antiretroviral therapy (ART) who visited any one of 64 facilities across 4 provinces in Zambia during the 24-month period from 1 August 2013 to 31 July 2015. We identified a probability sample of patients who were lost to follow-up through selecting facilities probability proportional to size and then a simple random sample of lost patients. Outcomes among patients lost to follow-up were incorporated into survival analysis and multivariate regression through probability weights. Of 165,464 individuals (64% female, median age 39 years (IQR 33-46), median CD4 201 cells/mm3 (IQR 111-312), the 2-year cumulative incidence of mortality increased from 1.9% (95% CI 1.7%-2.0%) to a corrected rate of 7.0% (95% CI 5.7%-8.4%) (all ART users) and from 2.1% (95% CI 1.8%-2.4%) to 8.3% (95% CI 6.1%-10.7%) (new ART users). Revised provincial mortality rates ranged from 3-9 times higher than naïve rates for new ART users and were lowest in Lusaka Province (4.6 per 100 person-years) and highest in Western Province (8.7 per 100 person-years) after correction. Corrected mortality rates varied markedly by clinic, with an IQR of 3.5 to 7.5 deaths per 100 person-years and a high of 13.4 deaths per 100 person-years among new ART users, even after adjustment for clinical (e.g., pretherapy CD4) and contextual (e.g., province and clinic size) factors. Mortality rates (all ART users) were highest year 1 after treatment at 4.6/100 person-years (95% CI 3.9-5.5), 2.9/100 person-years (95% CI 2.1-3.9) in year 2, and approximately 1.6% per year through 8 years on treatment. In multivariate analysis, patient-level factors including male sex and pretherapy CD4 levels and WHO stage were associated with higher mortality among new ART users, while male sex and HIV disclosure were associated with mortality among all ART users. In both cases, being late (>14 days late for appointment) or lost (>90 days late for an appointment) was associated with deaths. We were unable to ascertain the vital status of about one-quarter of those lost and selected for tracing and did not adjudicate causes of death. CONCLUSIONS HIV treatment in Zambia is not optimally effective. The high and sustained mortality rates and marked under-reporting of mortality at the provincial-level and unexplained heterogeneity between regions and sites suggest opportunities for the use of corrected mortality rates for quality improvement. A regionally representative sampling-based approach can bring gaps and opportunities for programs into clear epidemiological focus for local and global decision makers.
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Affiliation(s)
- Charles B Holmes
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.,Johns Hopkins University, Baltimore, Maryland, United States of America.,Georgetown University, Washington, DC, United States of America
| | - Izukanji Sikazwe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | | | | | - Nancy Czaicki
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.,University of California, Berkeley, Berkeley, California, United States of America
| | - Laura K Beres
- Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Njekwa Mukamba
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Sandra Simbeza
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Carolyn Bolton Moore
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.,University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Cardinal Hantuba
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Peter Mwaba
- Lusaka Apex Medical University, Lusaka, Zambia
| | - Caroline Phiri
- Ministry of Health, Government of the Republic of Zambia, Lusaka, Zambia
| | - Nancy Padian
- University of California, Berkeley, Berkeley, California, United States of America
| | - David V Glidden
- University of California, San Francisco, San Francisco, California, United States of America
| | - Elvin Geng
- University of California, San Francisco, San Francisco, California, United States of America
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Affiliation(s)
- I Eshun-Wilson
- Division of Infectious Diseases, Department of Medicine, Tygerberg Academic Hospital, University of Stellenbosch, South Africa
| | - M.D. Zeier
- Division of Infectious Diseases, Department of Medicine, Tygerberg Academic Hospital, University of Stellenbosch, South Africa
| | - J Barnes
- Department of Community Health, Faculty of Health Sciences, University of Stellenbosch, South Africa
| | - J.J. Taljaard
- Division of Infectious Diseases, Department of Medicine, Tygerberg Academic Hospital, University of Stellenbosch, South Africa
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Affiliation(s)
- Ingrid Eshun-Wilson
- University of Cape Town; Department of Family Medicine; Cape Town South Africa
| | - Dickens H Akena
- Makerere University, College of Health Sciences; Department of Psychiatry; KAMPALA Uganda
| | - Nandi Siegfried
- University of Cape Town; Department of Psychiatry and Mental Health; Education Centre, Valkenberg Hospital Private Bag X1, Observatory Cape Town South Africa 7925
- University of California, San Francisco; Department of Epidemiology and Biostatistics; San Francisco California USA
- School of Public Health and Family Medicine, University of Cape Town; Centre for Infectious Disease and Epidemiology Research (CIDER); Cape Town South Africa
| | - Ekwaro Obuku
- College of Health Sciences, Makerere University; Africa Centre for Systematic Reviews & Knowledge Translation; Kampala Uganda
| | - Dan J Stein
- University of Cape Town; Department of Psychiatry and Mental Health; Education Centre, Valkenberg Hospital Private Bag X1, Observatory Cape Town South Africa 7925
| | - John A. Joska
- University of Cape Town; Department of Psychiatry and Mental Health; Education Centre, Valkenberg Hospital Private Bag X1, Observatory Cape Town South Africa 7925
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