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Wang L, Muwonge TR, Simoni JM, Nambi F, Nakabugo L, Kibuuka J, Thomas D, Katz IT, Feutz E, Thomas KK, Ware NC, Wyatt MA, Kadama H, Mujugira A, Heffron R. Behavioral Modeling and its Association with PrEP and ART Use in Ugandan HIV-Serodifferent Couples. AIDS Behav 2024; 28:1719-1730. [PMID: 38361169 PMCID: PMC11069469 DOI: 10.1007/s10461-024-04286-2] [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] [Accepted: 01/29/2024] [Indexed: 02/17/2024]
Abstract
Integrating Pre-Exposure Prophylaxis (PrEP) delivery into Antiretroviral Therapy (ART) programs bridges the Human Immunodeficiency Virus (HIV) prevention gap for HIV-serodifferent couples prior to the partner living with HIV achieving viral suppression. Behavioral modeling is one mechanism that could explain health-related behavior among couples, including those using antiretroviral medications, but few tools exist to measure the extent to which behavior is modeled. Using a longitudinal observational design nested within a cluster randomized trial, this study examined the factor structure and assessed the internal consistency of a novel 24-item, four-point Likert-type scale to measure behavioral modeling and the association of behavioral modeling with medication-taking behaviors among heterosexual, cis-gender HIV-serodifferent couples. In 149 couples enrolled for research, a five-factor model provided the best statistical and conceptual fit, including attention to partner behavior, collective action, role modeling, motivation, and relationship quality. Behavioral modeling was associated with medication-taking behaviors among members of serodifferent couples. Partner modeling of ART/PrEP taking could be an important target for assessment and intervention in HIV prevention programs for HIV serodifferent couples.
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Affiliation(s)
- Liying Wang
- Department of Psychology, University of Washington, Seattle, WA, USA
| | | | - Jane M Simoni
- Department of Psychology, University of Washington, Seattle, WA, USA
- Department of Global Health, University of Washington, Seattle, WA, USA
- Behavioral and Social Sciences Research, NIH, Bethesda, Maryland, USA
- Office of Behavioral and Social Sciences Research (OBSSR), NIH, Bethesda, Maryland, USA
- Division of Program Coordination, Planning and Strategic Initiatives (DPCPSI), NIH, Bethesda, Maryland, USA
- National Institutes of Health (NIH), Bethesda, Maryland, USA
| | - Florence Nambi
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | - Joseph Kibuuka
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Dorothy Thomas
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Ingrid T Katz
- Department of Global Health and Social Medicine, Harvard Medical School, 25 Shattuck St, Boston, Massachusetts, USA
- Department of Medicine, Brigham and Women's Hospital, 75 Francis St, Boston, Massachusetts, USA
| | - Erika Feutz
- Department of Global Health, University of Washington, Seattle, WA, USA
| | | | - Norma C Ware
- Department of Global Health and Social Medicine, Harvard Medical School, 25 Shattuck St, Boston, Massachusetts, USA
- Department of Medicine, Brigham and Women's Hospital, 75 Francis St, Boston, Massachusetts, USA
| | - Monique A Wyatt
- Department of Global Health and Social Medicine, Harvard Medical School, 25 Shattuck St, Boston, Massachusetts, USA
- Harvard Global, Cambridge, MA, USA
| | | | - Andrew Mujugira
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Renee Heffron
- Department of Global Health, University of Washington, Seattle, WA, USA.
- Department of Medicine, University of Alabama at Birmingham, 845 19th Street South Bevill Biomedical Research Building, Room 256D, Birmingham, AL, 35294-2170, USA.
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Thomas D, Nakabugo L, Nambi F, Kibuuka J, Muwonge TR, Feutz E, Thomas KK, Simoni JM, Montgomery ET, Ware N, Wyatt MA, Katz IT, Kadama H, Mujugira A, Heffron R. Intimate Partner Violence and Adherence to PrEP and ART Among Ugandan HIV Serodifferent Couples. J Acquir Immune Defic Syndr 2024; 95:347-354. [PMID: 38133584 PMCID: PMC10896193 DOI: 10.1097/qai.0000000000003368] [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: 05/31/2023] [Accepted: 11/06/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Intimate partner violence (IPV) is associated with increased risk of HIV acquisition and reduced engagement in HIV care. There is limited understanding of the ways in which IPV exposure and other maladaptive relationship dynamics may influence adherence to antiretroviral treatment (ART) and pre-exposure prophylaxis (PrEP) for individuals in committed, HIV serodifferent partnerships. METHODS We used binomial generalized linear mixed-effect regression models to evaluate the association between IPV exposure and ART/PrEP adherence among members of serodifferent couples in Uganda. Secondarily, we assessed the association between relationship powerlessness and ART/PrEP adherence. RESULTS We enrolled and followed both partners in 149 heterosexual serodifferent couples. The partner living with HIV was female in 64% of couples. IPV exposure was associated with low ART adherence (15% vs. 5% in quarters with no IPV, odds ratio: 4.78, 95% confidence interval: 1.48 to 15.42), but not low PrEP adherence (33% vs. 36%, P = 0.69). Among HIV-negative individuals, those reporting moderate relationship powerlessness were less likely to have poor PrEP adherence compared with those with low relationship powerlessness (20% vs. 30%, odds ratio: 0.57, 95% confidence interval: 0.36 to 0.90). We observed no association between relationship powerlessness and ART adherence. CONCLUSIONS We found that IPV exposure was associated with low adherence to ART and that relationship powerlessness was associated with good adherence to PrEP. These findings contribute to the evidence base outlining the influence of IPV and relationship power on ART/PrEP adherence for individuals in HIV serodifferent unions.
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Affiliation(s)
- Dorothy Thomas
- Department of Global Health, University of Washington, Seattle, WA
| | | | - Florence Nambi
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Joseph Kibuuka
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | - Erika Feutz
- Department of Global Health, University of Washington, Seattle, WA
| | | | - Jane M. Simoni
- Department of Global Health, University of Washington, Seattle, WA
- Department of Psychology, University of Washington, Seattle, WA
| | - Elizabeth T. Montgomery
- Women's Global Health Imperative, RTI International, Berkeley, CA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA
| | - Norma Ware
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA
- Brigham and Women's Hospital, Boston, MA
| | - Monique A. Wyatt
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA
- Harvard Global, Cambridge, MA
| | | | | | - Andrew Mujugira
- Department of Global Health, University of Washington, Seattle, WA
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Renee Heffron
- Department of Global Health, University of Washington, Seattle, WA
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL; and
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Nardell MF, Govathson‐Mandimika C, Garnier S, Watts A, Babalola D, Ngcobo N, Long L, Lurie MN, Miot J, Pascoe S, Katz IT. "Emotional stress is more detrimental than the virus itself": A qualitative study to understand HIV testing and pre-exposure prophylaxis (PrEP) use among internal migrant men in South Africa. J Int AIDS Soc 2024; 27:e26225. [PMID: 38462755 PMCID: PMC10935710 DOI: 10.1002/jia2.26225] [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: 08/22/2023] [Accepted: 02/07/2024] [Indexed: 03/12/2024] Open
Abstract
INTRODUCTION South Africa has one of the highest rates of internal migration on the continent, largely comprised of men seeking labour in urban centres. South African men who move within the country (internal migrants) are at higher risk than non-migrant men of acquiring HIV yet are less likely to test or use pre-exposure prophylaxis (PrEP). However, little is known about the mechanisms that link internal migration and challenges engaging in HIV services. METHODS We recruited 30 internal migrant men (born outside Gauteng Province) during August 2022 for in-depth qualitative interviews at two sites in Johannesburg (Gauteng) where migrants may gather, a factories workplace and a homeless shelter. Interviewers used open-ended questions, based in the Theory of Triadic Influence, to explore experiences and challenges with HIV testing and/or PrEP. A mixed deductive inductive content analytic approach was used to review data and explain why participants may or may not use these services. RESULTS Migrant men come to Johannesburg to find work, but unreliable income, daily stress and time constraints limit their availability to seek health services. While awareness of HIV testing is high, the fear of a positive diagnosis often overshadows the benefits. In addition, many men lack knowledge about the opportunity for PrEP should they test negative, though they express interest in the medication after learning about it. Additionally, these men struggle with adjusting to urban life, lack of social support and fear of potential stigma. Finally, the necessity to prioritize work combined with long wait times at clinics further restricts their access to HIV services. Despite these challenges, Johannesburg also presents opportunities for HIV services for migrant men, such as greater anonymity and availability of HIV information and services in the city as compared to their rural homes of origin. CONCLUSIONS Bringing HIV services to migrant men at community sites may ease the burden of accessing these services. Including PrEP counselling and services alongside HIV testing may further encourage men to test, particularly if integrated into counselling for livelihood and coping strategies, as well as support for navigating health services in Johannesburg.
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Affiliation(s)
- Maria Francesca Nardell
- Division of Global Health EquityBrigham and Women's HospitalBostonMassachusettsUSA
- Harvard Medical SchoolBostonMassachusettsUSA
| | - Caroline Govathson‐Mandimika
- Health Economics and Epidemiology Research Office (HE2RO)JohannesburgSouth Africa
- Faculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | | | | | | | - Nkosinathi Ngcobo
- Health Economics and Epidemiology Research Office (HE2RO)JohannesburgSouth Africa
- Faculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Lawrence Long
- Health Economics and Epidemiology Research Office (HE2RO)JohannesburgSouth Africa
- Faculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
- Department of Global HealthBoston University School of Public HealthBostonMassachusettsUSA
| | - Mark N. Lurie
- Brown University School of Public HealthBrown UniversityProvidenceRhode IslandUSA
| | - Jacqui Miot
- Health Economics and Epidemiology Research Office (HE2RO)JohannesburgSouth Africa
- Faculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Sophie Pascoe
- Health Economics and Epidemiology Research Office (HE2RO)JohannesburgSouth Africa
- Faculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Ingrid T. Katz
- Harvard Medical SchoolBostonMassachusettsUSA
- Division of Women's HealthBrigham and Women's HospitalBostonMassachusettsUSA
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Mudzingwa EK, de Vos L, Fynn L, Atujuna M, Katz IT, Hosek S, Celum C, Daniels J, Bekker LG, Medina-Marino A. Youth-friendly services was the magic: Experiences of adolescent girls and young women in the community PrEP study, South Africa. Glob Public Health 2024; 19:2349918. [PMID: 38752416 PMCID: PMC11101151 DOI: 10.1080/17441692.2024.2349918] [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: 10/17/2023] [Accepted: 04/24/2024] [Indexed: 05/19/2024]
Abstract
Adherence to daily oral pre-exposure prophylaxis (PrEP) for HIV prevention has been challenging for adolescent girls and young women (AGYW). As part of The Community PrEP Study (CPS), AGYW were randomised to HIV-prevention empowerment counselling (intervention) or basic medication pick-up (control). In this qualitative sub-study, we interviewed AGYW participants (n = 39) to explore PrEP use and study experiences by study arm, and study staff (n = 7) to explore study implementation, site environment, and participant engagement. Data were thematically analysed using a constant comparison approach. Comparative matrices assessed similarities and differences in study experiences and PrEP support preferences. Friendly, non-judgmental, non-stigmatizing study staff were described as central to participant's positive experiences. Participants highly valued CPS staff's holistic health support (e.g. physical and psycho-social). Intervention participants described empowerment counselling as helpful in supporting PrEP disclosure. However, control participants also described disclosing PrEP use to trusted individuals. Participants and staff recommended public-sector PrEP services provide holistic, confidential, and integrated sexual and reproductive health services, and community sensitisation. An adolescent and youth-friendly environment was the primary factor motivating AGYW's study engagement. While HIV-prevention empowerment counselling was well received, welcoming, respectful and non-judgmental staff may be the 'secret sauce' for implementing effective PrEP services to AGYW.
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Affiliation(s)
- Emily Krogstad Mudzingwa
- The Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
- Institute for Collaboration on Health, Intervention, and Policy, University of Connecticut, Storrs, Connecticut, USA
| | - Lindsey de Vos
- Research Unit, Foundation for Professional Development, East London, South Africa
| | - Lauren Fynn
- The Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Millicent Atujuna
- The Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Ingrid T. Katz
- Harvard Medical School, Boston, MA, USA
- Division of Women’s Health, Brigham and Women’s Hospital, Boston, MA, USA
| | - Sybil Hosek
- Department of Medicine, University of Illinois Chicago, Chicago, Illinois, USA
| | - Connie Celum
- Departments of Global Health, Medicine, and Epidemiology, University of Washington, Seattle, Washington, USA
| | - Joseph Daniels
- Departments of Global Health, Medicine, and Epidemiology, University of Washington, Seattle, Washington, USA
- Edson College of Nursing and Health Innovation, Arizona State University, Phoenix, USA
| | - Linda-Gail Bekker
- The Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Andrew Medina-Marino
- The Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
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Nkengasong J, Ruffner M, Bartee M, Katz IT, Reid MJA. Sustaining the HIV/AIDS response: PEPFAR's vision. J Int AIDS Soc 2023; 26:e26192. [PMID: 38031907 PMCID: PMC10687756 DOI: 10.1002/jia2.26192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 11/10/2023] [Indexed: 12/01/2023] Open
Affiliation(s)
- John Nkengasong
- Bureau of Global Health Security and DiplomacyPresident's Emergency Plan for AIDS ReliefWashingtonDCUSA
| | - Michael Ruffner
- Bureau of Global Health Security and DiplomacyPresident's Emergency Plan for AIDS ReliefWashingtonDCUSA
| | - Maureen Bartee
- Bureau of Global Health Security and DiplomacyPresident's Emergency Plan for AIDS ReliefWashingtonDCUSA
| | - Ingrid T. Katz
- Bureau of Global Health Security and DiplomacyPresident's Emergency Plan for AIDS ReliefWashingtonDCUSA
- Department of MedicineBrigham Women's Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Michael J. A. Reid
- Bureau of Global Health Security and DiplomacyPresident's Emergency Plan for AIDS ReliefWashingtonDCUSA
- Institute for Global Health SciencesUniversity of California at San FranciscoSan FranciscoCaliforniaUSA
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6
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Nkengasong J, Reid M, Katz IT. This is how the world finally ends the HIV/AIDS pandemic. Nature 2023; 623:907-909. [PMID: 38017267 DOI: 10.1038/d41586-023-03715-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2023]
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Nardell MF, Sindelo S, Rousseau E, Siko N, Fuzile P, Julies R, Bassett IV, Mellins CA, Bekker LG, Butler LM, Katz IT. Development of "Yima Nkqo," a community-based, peer group intervention to support treatment initiation for young adults with HIV in South Africa. PLoS One 2023; 18:e0280895. [PMID: 37319250 PMCID: PMC10270624 DOI: 10.1371/journal.pone.0280895] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 01/11/2023] [Indexed: 06/17/2023] Open
Abstract
AIMS Half of young adults diagnosed with HIV in South Africa start antiretroviral therapy (ART). We developed and field tested a facilitator-guided peer support group called Yima Nkqo ("Standing Tall" in isiXhosa) to promote treatment initiation for young adults newly diagnosed with HIV in communities around Cape Town. METHODS Following an adapted version of the UK Medical Research Council's framework for developing complex interventions, we 1) identified evidence on previous interventions to improve ART uptake in sub-Saharan Africa; 2) collected and analyzed qualitative data on the acceptability of our proposed intervention; 3) proposed a theoretical understanding of the process of behavior change; and 4) developed an intervention manual and feedback tools. During field-testing, participant feedback on intervention acceptability, and team feedback on consistency of content delivery and facilitation quality, were analyzed using an iterative, rapid-feedback evaluation approach. In-depth written and verbal summaries were shared in weekly team meetings. Team members interpreted feedback, identified areas for improvement, and proposed suggestions for intervention modifications. RESULTS Based on our formative research, we developed three, 90-minute sessions with content including HIV and ART education, reflection on personal resources and strengths, practice disclosing one's status, strategies to overcome stressors, and goal setting to start treatment. A lay facilitator was trained to deliver intervention content. Two field testing groups (five and four participants, respectively) completed the intervention. Participants highlighted that strengths of Yima Nkqo included peer support, motivation, and education about HIV and ART. Team feedback to the facilitator ensured optimal consistency of intervention content delivery. CONCLUSIONS Iteratively developed in collaboration with youth and healthcare providers, Yima Nkqo is a promising new intervention to improve treatment uptake among young adults with HIV in South Africa. The next phase will be a pilot randomized controlled trial of Yima Nkqo (ClinicalTrials.gov Identifier: NCT04568460).
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Affiliation(s)
- Maria F. Nardell
- Division of Global Health Equity, Brigham and Women’s Hospital, Boston, MA, United States of America
- Harvard Medical School, Boston, MA, United States of America
- Department of Medicine, Brigham and Women’s Hospital, Boston, MA, United States of America
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States of America
| | - Siyaxolisa Sindelo
- The Desmond Tutu Health Foundation, University of Cape Town, Cape Town, Republic of South Africa
| | - Elzette Rousseau
- The Desmond Tutu Health Foundation, University of Cape Town, Cape Town, Republic of South Africa
| | - Nomakaziwe Siko
- The Desmond Tutu Health Foundation, University of Cape Town, Cape Town, Republic of South Africa
| | - Pamela Fuzile
- The Desmond Tutu Health Foundation, University of Cape Town, Cape Town, Republic of South Africa
| | - Robin Julies
- The Desmond Tutu Health Foundation, University of Cape Town, Cape Town, Republic of South Africa
| | - Ingrid V. Bassett
- Harvard Medical School, Boston, MA, United States of America
- Center for Global Health, Massachusetts General Hospital, Boston, MA, United States of America
| | - Claude A. Mellins
- HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute and Columbia University, New York, NY, United States of America
| | - Linda-Gail Bekker
- The Desmond Tutu Health Foundation, University of Cape Town, Cape Town, Republic of South Africa
- Department of Medicine, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, Republic of South Africa
- Governing Council, International AIDS Society, Geneva, Switzerland
| | - Lisa M. Butler
- Institute for Collaboration on Health, Intervention and Policy, University of Connecticut, Storrs, CT, United States of America
| | - Ingrid T. Katz
- Harvard Medical School, Boston, MA, United States of America
- Department of Medicine, Brigham and Women’s Hospital, Boston, MA, United States of America
- Harvard Global Health Institute, Harvard University, Cambridge, MA, United States of America
- Division of Women’s Health, Brigham and Women’s Hospital, Boston, MA, United States of America
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Nkengasong J, Zaidi I, Katz IT. PEPFAR at 20-Looking Back and Looking Ahead. JAMA 2023:2806189. [PMID: 37294580 DOI: 10.1001/jama.2023.9291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- John Nkengasong
- Office of the US Global AIDS Coordinator and Health Diplomacy, US Department of State, Washington, DC
| | - Irum Zaidi
- Office of the US Global AIDS Coordinator and Health Diplomacy, US Department of State, Washington, DC
| | - Ingrid T Katz
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Katz IT, Ngure K, Kamolloh K, Ogello V, Okombo M, Thuo NB, Owino E, Garrison LE, Lee YS, Nardell MF, Anyacheblu C, Bukusi E, Mugo N, Baeten JM, Haberer JE. Multi-level Factors Driving Pre-exposure Prophylaxis Non-initiation Among Young Women at High Risk for HIV in Kenya. AIDS Behav 2023; 27:106-118. [PMID: 35930203 DOI: 10.1007/s10461-022-03748-9] [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] [Accepted: 06/06/2022] [Indexed: 01/29/2023]
Abstract
Few studies have focused on understanding pre-exposure prophylaxis (PrEP) non-initiation among young, high-risk women in sub-Saharan Africa. This study aimed to qualitatively explore why young women in Kenya at high-risk for HIV chose not to enroll in a PrEP adherence trial. We performed 40 semi-structured interviews with young high-risk women assessing concerns about PrEP and/or study participation. We also assessed community-level factors influencing decision-making around PrEP through 10 focus groups involving peers, young men, caregivers, and community leaders. Our qualitative data reflect the complexity of navigating barriers preventing PrEP initiation in settings where taking PrEP may be perceived as immoral behavior. Framed within the context of risk perception, the decision to start PrEP may run counter to the potential risk of losing support from one's community. Our findings suggest that approaches addressing social norms, while de-medicalizing HIV prevention services, are needed to further increase PrEP uptake among young Kenyan women.
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Affiliation(s)
- 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. .,Division of Women's Health, Brigham and Women's Hospital, 1620 Tremont St. - 3rd Floor, Boston, MA, 02120, USA.
| | - Kenneth Ngure
- Department of Community Health, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
| | | | | | - Moses Okombo
- Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Esther Owino
- Kenya Medical Research Institute, Nairobi, Kenya
| | - Lindsey E Garrison
- Massachusetts General Hospital Center for Global Health, Boston, MA, USA
| | - Yeonsoo S Lee
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Mayo Clinic Alix School of Medicine, Scottsdale, AZ, USA
| | - Maria F Nardell
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Chiemelie Anyacheblu
- Harvard T.H Chan School of Public Health, Boston, MA, USA.,SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - Elizabeth Bukusi
- Kenya Medical Research Institute, Nairobi, Kenya.,Department of Obstetrics and Gynecology, University of Washington, Seattle, WA, USA
| | - Nelly Mugo
- Kenya Medical Research Institute, Nairobi, Kenya.,Department of Global Health, Medicine, and Epidemiology, University of Washington, Seattle, WA, USA
| | - Jared M Baeten
- Department of Global Health, Medicine, and Epidemiology, University of Washington, Seattle, WA, USA.,Gilead Sciences, Foster City, CA, USA
| | - Jessica E Haberer
- Harvard Medical School, Boston, MA, USA.,Massachusetts General Hospital Center for Global Health, Boston, MA, USA
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Heffron R, Muwonge TR, Thomas KK, Nambi F, Nakabugo L, Kibuuka J, Thomas D, Feutz E, Meisner A, Ware NC, Wyatt MA, Simoni JM, Katz IT, Kadama H, Baeten JM, Mujugira A. PrEP uptake and HIV viral suppression when PrEP is integrated into Ugandan ART clinics for HIV-negative members of HIV-serodifferent couples: A stepped wedge cluster randomized trial. EClinicalMedicine 2022; 52:101611. [PMID: 35990584 PMCID: PMC9386395 DOI: 10.1016/j.eclinm.2022.101611] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [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: 05/27/2022] [Revised: 07/15/2022] [Accepted: 07/22/2022] [Indexed: 11/11/2022] Open
Abstract
Background Global scale-up of HIV pre-exposure prophylaxis (PrEP) includes services to HIV-negative people in partnerships with people living with HIV (serodifferent couples). Data are needed on HIV outcomes, including uptake and adherence to PrEP and antiretroviral treatment (ART), to describe the impact of integrating PrEP into an existing HIV program. Methods Using a stepped-wedge cluster randomized trial design, we launched PrEP delivery for HIV-negative members of serodifferent couples in Uganda by integrating PrEP into existing ART programs for people living with HIV. The program provided PrEP training for ART providers, ongoing technical assistance, and a provisional supply chain mechanism for PrEP medication. Primary data on PrEP initiation, PrEP refills, ART initiation, and HIV viremia at 6 months (measured at 42-270 days) were collected through data abstraction of medical records from HIV-serodifferent couples sequentially enrolling at the ART clinics. Modified Poisson regression models, controlling for time and cluster, compared viral suppression (<1000 copies/ml) before and after launch of the PrEP program. This trial was registered at ClinicalTrials.gov, NCT03586128. Findings From June 1, 2018-December 15, 2020, 1,381 HIV-serodifferent couples were enrolled across 12 ART clinics in Kampala and Wakiso, Uganda, including 730 enrolled before and 651 after the launch of PrEP delivery. During the baseline period, 99.4% of partners living with HIV initiated ART and 85.0% were virally suppressed at 6 months. Among HIV-negative partners enrolled after PrEP launched, 81.0% (527/651) initiated PrEP within 90 days of enrolling; among these 527, 11.2% sought a refill 6 months later. In our powered intent-to-treat analysis, 82.1% and 76.7% of partners living with HIV were virally suppressed, respectively, which was not a statistically significant difference (RR=0.94, 95% CI: 0.82-1.07) and was stable across sensitivity analyses. Interpretation Integration of PrEP into ART clinics reached a high proportion of people in HIV-serodifferent relationships and did not improve the already high frequency of HIV viral suppression among partners living with HIV. Funding National Institute of Mental Health (R01MH110296).
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Affiliation(s)
- Renee Heffron
- University of Washington, 325 Ninth Avenue, Box 359927 Seattle, Washington, USA
- University of Alabama Birmingham, Birmingham, Alabama, USA
| | | | - Katherine K. Thomas
- University of Washington, 325 Ninth Avenue, Box 359927 Seattle, Washington, USA
| | - Florence Nambi
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | - Joseph Kibuuka
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Dorothy Thomas
- University of Washington, 325 Ninth Avenue, Box 359927 Seattle, Washington, USA
| | - Erika Feutz
- University of Washington, 325 Ninth Avenue, Box 359927 Seattle, Washington, USA
| | - Allison Meisner
- University of Washington, 325 Ninth Avenue, Box 359927 Seattle, Washington, USA
- Fred Hutch, Vaccine and Infectious Disease Division, 1100 Fairview Ave N, Seattle, Washington, USA
| | - Norma C. Ware
- Harvard Medical School, 25 Shattuck St., Boston, Massachusetts, USA
- Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, Massachusetts, USA
| | - Monique A. Wyatt
- Harvard Medical School, 25 Shattuck St., Boston, Massachusetts, USA
- Harvard Global, Cambridge, Massachusetts, USA
| | - Jane M. Simoni
- University of Washington, 325 Ninth Avenue, Box 359927 Seattle, Washington, USA
| | - Ingrid T. Katz
- Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, Massachusetts, USA
| | | | - Jared M. Baeten
- University of Washington, 325 Ninth Avenue, Box 359927 Seattle, Washington, USA
- Gilead Sciences LLC, Foster City, California, USA
| | - Andrew Mujugira
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
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11
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Nardell MF, Hedt-Gauthier B, Earnshaw VA, Bogart LM, Dietrich JJ, Courtney I, Tshabalala G, Bor J, Orrell C, Gray G, Bangsberg DR, Katz IT. Understanding Repeat Positive HIV Testing in South Africa Under Changing Treatment Guidelines. AIDS Behav 2022; 26:1366-1376. [PMID: 34705150 PMCID: PMC9007825 DOI: 10.1007/s10461-021-03493-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [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] [Accepted: 10/08/2021] [Indexed: 01/06/2023]
Abstract
Some people with HIV (PWH) test positive multiple times without initiating antiretroviral therapy (ART). We surveyed 496 ART-eligible PWH following routine HIV testing at three clinics in Soweto and Gugulethu, South Africa in 2014-2015. Among repeat positive testers (RPTs) in this cohort, we compared rates of treatment initiation by prior treatment eligibility and assessed psychosocial predictors of treatment initiation in logistic regression models. RPTs represented 33.8% of PWH in this cohort. Less than half of those who reported eligibility for ART on prior testing started treatment upon retesting, in contrast to two thirds of RPTs who were previously ineligible for treatment who started treatment once they learned of their eligibility. Those who reported coping through substance use were more likely to decline treatment versus those not using substances. PWH who test repeatedly represent a vulnerable population at risk for ART non-initiation who may benefit from interventions addressing individualized coping strategies.
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Affiliation(s)
- Maria F Nardell
- Division of Global Health Equity, Brigham and Women's Hospital, Thorn Building 14th Floor, Boston, MA, 02120, USA.
- Harvard Medical School, Boston, USA.
- Department of Medicine, Brigham and Women's Hospital, Boston, USA.
| | - Bethany Hedt-Gauthier
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA
- Massachusetts General Hospital Center for Global Health, Boston, USA
| | - Valerie A Earnshaw
- Department of Human Development and Family Sciences, University of Delaware, Newark, USA
| | | | - Janan J Dietrich
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- Health Systems Research Unit, South African Medical Research Council, Western Cape, South Africa
| | - Ingrid Courtney
- Desmond Tutu Health Foundation, University of Cape Town Medical School, Cape Town, South Africa
| | - Gugulethu Tshabalala
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Jacob Bor
- Department of Global Health, Boston University School of Public Health, Boston, USA
| | - Catherine Orrell
- Desmond Tutu Health Foundation, University of Cape Town Medical School, Cape Town, South Africa
| | - Glenda Gray
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- Office of the President, South African Medical Research Council, Western Cape, South Africa
| | - David R Bangsberg
- Oregon Health & Science University-Portland State University School of Public Health, Portland, USA
| | - Ingrid T Katz
- Harvard Medical School, Boston, USA
- Department of Medicine, Brigham and Women's Hospital, Boston, USA
- Massachusetts General Hospital Center for Global Health, Boston, USA
- Harvard Global Health Institute, Cambridge, USA
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12
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Figueroa JF, Katz IT, Hyle EP, Horneffer KE, Nambiar K, Phelan J, Orav EJ, Jha AK. The Association Of HIV With Health Care Spending And Use Among Medicare Beneficiaries. Health Aff (Millwood) 2022; 41:581-588. [PMID: 35377765 PMCID: PMC9153068 DOI: 10.1377/hlthaff.2021.01793] [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] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
An increasingly older population of people with HIV raises concerns about how HIV may influence care for Medicare patients. We therefore sought to determine the extent to which HIV influences additional spending on and use of mental health and medical care among Medicare beneficiaries and, importantly, whether treatment with antiretroviral therapy may reduce this additional spending. Using 2016 Medicare claims, we compared risk-adjusted spending and utilization for Medicare beneficiaries with and without HIV, as well as subgroups of people receiving antiretroviral therapy (ART). Compared to beneficiaries without HIV, those with HIV receiving ART incurred 220.6 percent more spending, mostly driven by ART spending, whereas those with HIV not receiving ART incurred 95.4 percent more spending. Among beneficiaries with HIV, those receiving more months of ART had lower spending on treatment for other chronic conditions relative to those receiving fewer months of ART in a dose-response manner. Beneficiaries with HIV not receiving ART incurred the highest spending related to infections, mental health disorders, and other medical conditions compared to beneficiaries in other HIV subgroups receiving ART for various numbers of months. Our findings suggest that ART may be associated with Medicare Parts A and B savings, but ART adherence and the high prices of HIV drugs in Part D need to be addressed.
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Affiliation(s)
- José F Figueroa
- José F. Figueroa , Harvard University and Brigham and Women's Hospital, Boston, Massachusetts
| | - Ingrid T Katz
- Ingrid T. Katz, Harvard University and Brigham and Women's Hospital
| | - Emily P Hyle
- Emily P. Hyle, Harvard University and Brigham and Women's Hospital
| | | | - Kavya Nambiar
- Kavya Nambiar, Brown University, Providence, Rhode Island
| | | | - E John Orav
- E. John Orav, Harvard University and Brigham and Women's Hospital
| | - Ashish K Jha
- Ashish K. Jha, Brown University and Providence Veterans Affairs Medical Center, Providence, Rhode Island
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13
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Nardell MF, Adeoti O, Peters C, Kakuhikire B, Govathson-Mandimika C, Long L, Pascoe S, Tsai AC, Katz IT. Men missing from the HIV care continuum in sub-Saharan Africa: a meta-analysis and meta-synthesis. J Int AIDS Soc 2022; 25:e25889. [PMID: 35324089 PMCID: PMC8944222 DOI: 10.1002/jia2.25889] [Citation(s) in RCA: 2] [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: 05/14/2021] [Accepted: 02/01/2022] [Indexed: 02/03/2023] Open
Abstract
Introduction Men are missing along the HIV care continuum. However, the estimated proportions of men in sub‐Saharan Africa meeting the UNAIDS 95‐95‐95 goals vary substantially between studies. We sought to estimate proportions of men meeting each of the 95‐95‐95 goals across studies in sub‐Saharan Africa, describe heterogeneity, and summarize qualitative evidence on factors influencing care engagement. Methods We systematically searched PubMed and Embase for peer‐reviewed articles published between 1 January 2014 and 16 October 2020. We included studies involving men ≥15 years old, with data from 2009 onward, reporting on at least one 95‐95‐95 goal in sub‐Saharan Africa. We estimated pooled proportions of men meeting these goals using DerSimonion‐Laird random effects models, stratifying by study population (e.g. studies focusing exclusively on men who have sex with men vs. studies that did not), facility setting (healthcare vs. community site), region (eastern/southern Africa vs. western/central Africa), outcome measurement (e.g. threshold for viral load suppression), median year of data collection (before vs. during or after 2017) and quality criteria. Data from qualitative studies exploring barriers to men's HIV care engagement were summarized using meta‐synthesis. Results and discussion We screened 14,896 studies and included 129 studies in the meta‐analysis, compiling data over the data collection period. Forty‐seven studies reported data on knowledge of serostatus, 43 studies reported on antiretroviral therapy use and 74 studies reported on viral suppression. Approximately half of men with HIV reported not knowing their status (0.49 [95% CI, 0.41–0.58; range, 0.09–0.97]) or not being on treatment (0.58 [95% CI, 0.51–0.65; range, 0.07–0.97]), while over three‐quarters of men achieved viral suppression on treatment (0.79 [95% CI, 0.77–0.81; range, 0.39–0.97]. Heterogeneity was high, with variation in estimates across study populations, settings and outcomes. The meta‐synthesis of 40 studies identified three primary domains in which men described risks associated with engagement in HIV care: perceived social norms, health system challenges and poverty. Conclusions Psychosocial and systems‐level interventions that change men's perceptions of social norms, improve trust in and accessibility of the health system, and address costs of accessing care are needed to better engage men, especially in HIV testing and treatment.
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Affiliation(s)
- Maria F Nardell
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Oluwatomi Adeoti
- Department of Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Carson Peters
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa, USA
| | - Bernard Kakuhikire
- Faculty of Business and Management Sciences, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Caroline Govathson-Mandimika
- Health Economics and Epidemiology Research Office, University of the Witwatersrand, Johannesburg, South Africa.,Department of Internal Medicine, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Lawrence Long
- Health Economics and Epidemiology Research Office, University of the Witwatersrand, Johannesburg, South Africa.,Department of Internal Medicine, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa.,Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Sophie Pascoe
- Health Economics and Epidemiology Research Office, University of the Witwatersrand, Johannesburg, South Africa.,Department of Internal Medicine, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Alexander C Tsai
- Harvard Medical School, Boston, Massachusetts, USA.,Mongan Institute, Massachusetts General Hospital, Boston, Massachusetts, USA.,Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ingrid T Katz
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Global Health Institute, Cambridge, Massachusetts, USA
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14
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Li P, Gao L, Gao C, Parker RA, Katz IT, Montano MA, Hu K. Daytime Sleep Behaviors and Cognitive Performance in Middle- to Older-Aged Adults Living with and without HIV Infection. Nat Sci Sleep 2022; 14:181-191. [PMID: 35173500 PMCID: PMC8843344 DOI: 10.2147/nss.s339230] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 09/27/2021] [Accepted: 01/20/2022] [Indexed: 12/11/2022] Open
Abstract
PURPOSE We investigated whether daytime sleep behaviors (DSBs) such as frequent daytime sleepiness or napping are associated with worse cognitive performance, and whether HIV infection moderates this relationship. METHODS Among 502,507 participants in the UK Biobank study, we identified 562 people living with HIV infection (PLWH; M age= 50.51±7.81; 25.09% female; 78.83% white) and extracted 562 uninfected controls who matched on age, sex, ethnic background, social-economic status, and comorbidities. DSB burden was assessed based on answers to two questions on DSBs. Participants who answered "sometimes" or "often/usually" to one of them were considered to have poor DSB burden, or otherwise were considered not having any. A composite cognition score was computed by averaging the available standardized individual test results from four neurocognitive tests: ie, a reaction time test for information processing speed, a pairs matching test for visual episodic memory, a fluid intelligence test for reasoning, and a prospective memory test. Mixed-effects models with adjustment for the variables used in extracting matched uninfected controls were performed to test the hypotheses. RESULTS Having poor DSB burden was associated with a 0.15 - standard deviation (SD) decrease in cognitive performance (p = 0.006). People living with HIV infection (PLWH) also performed worse on the cognitive tasks than uninfected controls, with an effect size similar to that of having poor DSB burden (p = 0.003). HIV infection significantly modified the negative association between DSB burden and cognition (p for interaction: 0.008). Specifically, the association between DSB burden and cognition was not statistically significant in uninfected controls, whereas PLWH who reported having poor DSB burden had a 0.28 - SD decrease in cognitive performance compared to PLWH who did not. CONCLUSION HIV infection significantly increased the adverse association between DSBs and cognitive performance. Further studies are needed to investigate the potential mechanisms that underlie this interaction effect and whether poor DSBs and worse cognitive performance are causally linked.
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Grants
- P30 AI060354 NIAID NIH HHS
- he Harvard University Center for AIDS Research (CFAR), an NIH funded program
- NIH Co-Funding and Participating Institutes and Centers: NIAID, NCI, NICHD, NHLBI, NIDA, NIMH, NIA, NIDDK, NIMHD, NIDCR, NINR, OAR, and FIC, by a Pilot Grant (to P.L.) sponsored by the AIDS and Aging Research Platform
- Foundation Alzheimer’s Disease Research Program
- the National Institute on Aging (NIA) grant
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Affiliation(s)
- Peng Li
- Medical Biodynamics Program, Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
- Division of Sleep Medicine, Harvard Medical School, Boston, MA, USA
- Correspondence: Peng Li, Email
| | - Lei Gao
- Medical Biodynamics Program, Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
- Division of Sleep Medicine, Harvard Medical School, Boston, MA, USA
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Chenlu Gao
- Medical Biodynamics Program, Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
- Division of Sleep Medicine, Harvard Medical School, Boston, MA, USA
| | - Robert A Parker
- Biostatistics Center, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Center for AIDS Research, Harvard University, Boston, MA, USA
| | - Ingrid T Katz
- Harvard Medical School, Boston, MA, USA
- Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
- Harvard Global Health Institute, Cambridge, MA, USA
| | - Monty A Montano
- Harvard Medical School, Boston, MA, USA
- Boston Claude D. Pepper Older Americans Independence Center, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Kun Hu
- Medical Biodynamics Program, Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
- Division of Sleep Medicine, Harvard Medical School, Boston, MA, USA
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15
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Katz IT, Musinguzi N, Bell K, Cross A, Bwana MB, Amanyire G, Asiimwe S, Orrell C, Bangsberg DR, Haberer JE. Brief Report: The Impact of Disease Stage on Early Gaps in ART in the "Treatment for All" Era-A Multisite Cohort Study. J Acquir Immune Defic Syndr 2021; 86:562-567. [PMID: 33351529 PMCID: PMC7938906 DOI: 10.1097/qai.0000000000002605] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 11/09/2020] [Indexed: 01/29/2023]
Abstract
BACKGROUND Adoption of "Treat All" policies has increased antiretroviral therapy (ART) initiation in sub-Saharan Africa; however, unexplained early losses continue to occur. More information is needed to understand why treatment discontinuation continues at this vulnerable stage in care. METHODS The Monitoring Early Treatment Adherence Study involved a prospective observational cohort of individuals initiating ART at early-stage versus late-stage disease in South Africa and Uganda. Surveys and HIV-1 RNA levels were performed at baseline, 6, and 12 months, with adherence monitored electronically. This analysis included nonpregnant participants in the first 6 months of follow-up; demographic and clinical factors were compared across groups with χ2, univariable, and multivariable models. RESULTS Of 669 eligible participants, 91 (14%) showed early gaps of ≥30 days in ART use (22% in South Africa and 6% in Uganda) with the median time to gap of 77 days (interquartile range: 43-101) and 87 days (74, 105), respectively. Although 71 (78%) ultimately resumed care, having an early gap was still significantly associated with detectable viremia at 6 months (P ≤ 0.01). Multivariable modeling, restricted to South Africa, found secondary education and higher physical health score protected against early gaps [adjusted odds ratio (aOR) 0.4, 95% confidence interval (CI): 0.2 to 0.8 and (aOR 0.93, 95% CI: 0.9 to 1.0), respectively]. Participants reporting clinics as "too far" had double the odds of early gaps (aOR 2.2: 95% CI: 1.2 to 4.1). DISCUSSION Early gaps in ART persist, resulting in higher odds of detectable viremia, particularly in South Africa. Interventions targeting health management and access to care are critical to reducing early gaps.
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Affiliation(s)
- Ingrid T. Katz
- Department of Medicine, Brigham and Women's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
- Harvard Global Health Institute, Cambridge, MA
| | | | - Kathleen Bell
- Massachusetts General Hospital Center for Global Health, Boston, MA
| | - Anna Cross
- Desmond Tutu HIV Foundation, University of Cape Town Medical School, Cape Town, South Africa
| | | | - Gideon Amanyire
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Stephen Asiimwe
- Mbarara University of Science and Technology, Mbarara, Uganda
- Kabwohe Clinical Research Center, Kabwohe, Uganda; and
| | - Catherine Orrell
- Desmond Tutu HIV Foundation, University of Cape Town Medical School, Cape Town, South Africa
| | - David R. Bangsberg
- Oregon Health and Science University-Portland State University School of Public Health, Portland, OR
| | - Jessica E. Haberer
- Harvard Medical School, Boston, MA
- Massachusetts General Hospital Center for Global Health, Boston, MA
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16
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Affiliation(s)
- Ingrid T Katz
- From the Department of Medicine, Brigham and Women's Hospital (I.T.K., R.W.), Harvard Medical School (I.T.K., R.W., A.M.B.), Massachusetts General Hospital Center for Global Health (I.T.K.), and Ariadne Labs (R.W.) - all in Boston; the Harvard Global Health Institute (I.T.K., A.M.B.), and Harvard University (A.M.B.) - both in Cambridge, MA; and the Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa (L.-G.B.)
| | - Rebecca Weintraub
- From the Department of Medicine, Brigham and Women's Hospital (I.T.K., R.W.), Harvard Medical School (I.T.K., R.W., A.M.B.), Massachusetts General Hospital Center for Global Health (I.T.K.), and Ariadne Labs (R.W.) - all in Boston; the Harvard Global Health Institute (I.T.K., A.M.B.), and Harvard University (A.M.B.) - both in Cambridge, MA; and the Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa (L.-G.B.)
| | - Linda-Gail Bekker
- From the Department of Medicine, Brigham and Women's Hospital (I.T.K., R.W.), Harvard Medical School (I.T.K., R.W., A.M.B.), Massachusetts General Hospital Center for Global Health (I.T.K.), and Ariadne Labs (R.W.) - all in Boston; the Harvard Global Health Institute (I.T.K., A.M.B.), and Harvard University (A.M.B.) - both in Cambridge, MA; and the Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa (L.-G.B.)
| | - Allan M Brandt
- From the Department of Medicine, Brigham and Women's Hospital (I.T.K., R.W.), Harvard Medical School (I.T.K., R.W., A.M.B.), Massachusetts General Hospital Center for Global Health (I.T.K.), and Ariadne Labs (R.W.) - all in Boston; the Harvard Global Health Institute (I.T.K., A.M.B.), and Harvard University (A.M.B.) - both in Cambridge, MA; and the Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa (L.-G.B.)
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17
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Nardell MF, Lee YS, Rousseau E, Julies R, Klaas P, Vundhla P, Butler L, Bassett IV, Mellins CA, Bekker LG, Katz IT. "You are not alone": a qualitative study to explore barriers to ART initiation and implications for a proposed community-based youth treatment club among young adults newly diagnosed with HIV in South Africa. AIDS Care 2020; 33:952-961. [PMID: 33345593 DOI: 10.1080/09540121.2020.1861179] [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] [Indexed: 10/22/2022]
Abstract
In South Africa, despite universal antiretroviral therapy (ART) availability, 60% of persons living with HIV (PLWH) ages 15-24 are not on treatment. This qualitative study aimed to identify barriers to ART initiation and the implications for a proposed community-based Youth Treatment Club to improve ART initiation for young PLWH in limited-resource, high HIV-prevalence communities in Cape Town, South Africa. Recruiting participants at community testing sites from 2018 to 2019, we conducted semi-structured interviews, informed by Social Action Theory (SAT), with 20 young adults, ages 18- to 24-years-old, newly diagnosed with HIV, along with 10 healthcare providers. Through systematic qualitative analysis, we found that young PLWH face barriers to treatment initiation in three SAT domains: (1) stigmatizing social norms (social regulation processes); (2) challenges coping with a new diagnosis (self-regulation processes); and (3) anticipated stigma in the clinic environment (contextual factors). Participants shared that a proposed community-based Youth Treatment Club for newly diagnosed youth would be an acceptable strategy to promote ART initiation. They emphasized that it should include supportive peers, trained facilitator support for counseling and education, and a youth-friendly environment.
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Affiliation(s)
- Maria F Nardell
- Connors Center for Women's Health and Gender Biology, Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Yeonsoo Sara Lee
- Division of Women's Health, Brigham and Women's Hospital, Boston, MA, USA
| | - Elzette Rousseau
- The Desmond Tutu Health Foundation, University of Cape Town, Cape Town, Republic of South Africa
| | - Robin Julies
- The Desmond Tutu Health Foundation, University of Cape Town, Cape Town, Republic of South Africa
| | - Portia Klaas
- The Desmond Tutu Health Foundation, University of Cape Town, Cape Town, Republic of South Africa
| | - Prisca Vundhla
- The Desmond Tutu Health Foundation, University of Cape Town, Cape Town, Republic of South Africa
| | - Lisa Butler
- Institute for Collaboration on Health, Intervention and Policy, University of Connecticut, Storrs, CT, USA
| | - Ingrid V Bassett
- Harvard Medical School, Boston, MA, USA.,Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
| | - Claude A Mellins
- HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute and Columbia University, New York, NY, USA
| | - Linda-Gail Bekker
- The Desmond Tutu Health Foundation, University of Cape Town, Cape Town, Republic of South Africa.,Institute of Infectious Disease and Molecular Medicine, Department of Medicine, University of Cape Town, Cape Town, Republic of South Africa.,Governing Council, International AIDS Society, Geneva, Switzerland
| | - Ingrid T Katz
- Harvard Medical School, Boston, MA, USA.,Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Division of Women's Health, Brigham and Women's Hospital, Boston, MA, USA.,Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA.,Harvard Global Health Institute, Harvard University, Cambridge, MA, USA
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18
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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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19
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Affiliation(s)
- Matthew M Kavanagh
- Department of International Health and O'Neill Institute for National and Global Health, Georgetown University, Washington, DC, USA.
| | - Ingrid T Katz
- Harvard Global Health Institute and Harvard Medical School, Harvard University, Boston, MA, USA
| | - Charles B Holmes
- Center for Innovation in Global Health, Georgetown University, Washington, DC, USA; School of Medicine, Johns Hopkins University, Baltimore, MD, USA
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20
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Siedner MJ, Bwana MB, Asiimwe S, Amanyire G, Musinguzi N, Castillo-Mancilla J, Tracy RP, Katz IT, Bangsberg DR, Hunt PW, Orrell C, Haberer JE. Timing of Antiretroviral Therapy and Systemic Inflammation in Sub-Saharan Africa: Results From the META Longitudinal Cohort Study. J Infect Dis 2020; 220:1172-1177. [PMID: 31188451 PMCID: PMC6736121 DOI: 10.1093/infdis/jiz259] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 05/16/2019] [Indexed: 11/14/2022] Open
Abstract
Chronic inflammation predicts complications in persons with human immunodeficiency virus infection. We compared D-dimer, soluble CD14, and interleukin 6 levels before and 12 months after antiretroviral therapy (ART) initiation, among individuals starting ART during earlier-stage (CD4 T-cell count >350/µL) or late-stage disease (CD4 T-cell count <200/µL). Female sex, older age, viral load, and late-stage disease were associated with pre-ART biomarkers (n = 661; P < .05). However, there were no differences in biomarkers by disease stage after 12 months of ART (n = 438; P > .05), owing to loss from observation and greater declines in biomarkers in late-stage initiators (P < .001). Earlier initiation of ART is associated with decreased inflammation, but levels seem to converge between earlier and later initiators surviving to 12 months.
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Affiliation(s)
- Mark J Siedner
- Harvard Medical School, Boston.,Massachusetts General Hospital, Boston.,Mbarara University of Science and Technology, Uganda.,Africa Health Research Institute, Kwa-Zulu Natal, South Africa
| | | | - Stephen Asiimwe
- Mbarara University of Science and Technology, Uganda.,Kabwohe Clinical Research Center, Uganda
| | | | | | | | | | - Ingrid T Katz
- Harvard Medical School, Boston.,Brigham and Women's Hospital, Boston
| | - David R Bangsberg
- Oregon Health & Science University-Portland State University School of Public Health, Portland
| | | | | | - Jessica E Haberer
- Harvard Medical School, Boston.,Massachusetts General Hospital, Boston
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21
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Affiliation(s)
| | - Ingrid T. Katz
- Harvard Medical School, Boston, Massachusetts
- Harvard Global Health Institute, Cambridge, Massachusetts
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22
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Affiliation(s)
- Mehul C Mehta
- From Harvard Global Health Institute, Cambridge, and Harvard Medical School (M.C.M., I.T.K., A.K.J.), Partners Healthcare International (M.C.M.), Brigham and Women's Hospital (I.T.K.), and Harvard T.H. Chan School of Public Health (A.K.J.), Boston - all in Massachusetts
| | - Ingrid T Katz
- From Harvard Global Health Institute, Cambridge, and Harvard Medical School (M.C.M., I.T.K., A.K.J.), Partners Healthcare International (M.C.M.), Brigham and Women's Hospital (I.T.K.), and Harvard T.H. Chan School of Public Health (A.K.J.), Boston - all in Massachusetts
| | - Ashish K Jha
- From Harvard Global Health Institute, Cambridge, and Harvard Medical School (M.C.M., I.T.K., A.K.J.), Partners Healthcare International (M.C.M.), Brigham and Women's Hospital (I.T.K.), and Harvard T.H. Chan School of Public Health (A.K.J.), Boston - all in Massachusetts
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23
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Colocci I, Perlo J, Rajagopal SS, Betancourt TS, Pradeep A, Mayer KH, Kumarasamy N, O'Cleirigh C, Katz IT, Chan BT. Economic vulnerability and non-initiation of antiretroviral therapy in India: a qualitative study. AIDS Care 2020; 33:423-427. [PMID: 31928214 DOI: 10.1080/09540121.2020.1713973] [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] [Indexed: 10/25/2022]
Abstract
In India, many people living with HIV (PLHIV) do not successfully initiate antiretroviral therapy (ART) after diagnosis. We conducted a clinic-based qualitative study at the Y.R. Gaitonde Centre for AIDS Research in Chennai, Tamil Nadu to explore factors that influence ART non-initiation. We interviewed 22 men and 15 women; median age was 42 (IQR, 36-48) and median CD4+ was 395 (IQR, 227-601). Participants were distrustful of HIV care freely available at nearby government facilities. Faced with the perceived need to access the private sector and therefore pay for medications and transportation costs, non-initiators with high CD4+ counts often decided to postpone ART until they experienced symptoms whereas non-initiators with low CD4+ counts often started ART but defaulted quickly after experiencing financial stressors or side effects. Improving perceptions of quality of care in the public sector, encouraging safe serostatus disclosure to facilitate stronger social support, and alleviating economic hardship may be important in encouraging ART initiation in India.
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Affiliation(s)
| | | | | | - Theresa S Betancourt
- School of Social Work and Research Program on Children and Adversity, Boston College, Boston, USA
| | - Amrose Pradeep
- Y.R. Gaitonde Centre for AIDS Research and Education, Chennai, India
| | - Kenneth H Mayer
- Fenway Health, Boston, USA.,Harvard Medical School, Boston, USA
| | | | - Conall O'Cleirigh
- Behavioral Medicine and Chester M. Pierce, MD Division of Global Psychiatry, Massachusetts General Hospital, Boston, USA
| | - Ingrid T Katz
- Harvard Medical School, Boston, USA.,Department of Medicine, Brigham and Women's Hospital, Boston, USA.,MGH Global Health, Massachusetts General Hospital, Boston, USA.,Harvard Global Health Institute, Cambridge, USA
| | - Brian T Chan
- Harvard Medical School, Boston, USA.,Department of Medicine, Brigham and Women's Hospital, Boston, USA
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24
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Affiliation(s)
- Dhruv S Kazi
- From the Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Beth Israel Deaconess Medical Center (D.S.K.), Harvard Medical School (D.S.K., I.T.K., A.K.J.), Brigham and Women's Hospital (I.T.K.), and the Harvard T.H. Chan School of Public Health (A.K.J.) - all in Boston; the University of California San Francisco Center for Vulnerable Populations, San Francisco (D.S.K.); and the Harvard Global Health Institute, Cambridge, MA (I.T.K., A.K.J.)
| | - Ingrid T Katz
- From the Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Beth Israel Deaconess Medical Center (D.S.K.), Harvard Medical School (D.S.K., I.T.K., A.K.J.), Brigham and Women's Hospital (I.T.K.), and the Harvard T.H. Chan School of Public Health (A.K.J.) - all in Boston; the University of California San Francisco Center for Vulnerable Populations, San Francisco (D.S.K.); and the Harvard Global Health Institute, Cambridge, MA (I.T.K., A.K.J.)
| | - Ashish K Jha
- From the Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Beth Israel Deaconess Medical Center (D.S.K.), Harvard Medical School (D.S.K., I.T.K., A.K.J.), Brigham and Women's Hospital (I.T.K.), and the Harvard T.H. Chan School of Public Health (A.K.J.) - all in Boston; the University of California San Francisco Center for Vulnerable Populations, San Francisco (D.S.K.); and the Harvard Global Health Institute, Cambridge, MA (I.T.K., A.K.J.)
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Katz IT, Bogart LM, Dietrich JJ, Leslie HH, Iyer HS, Leone D, Magidson JF, Earnshaw VA, Courtney I, Tshabalala G, Fitzmaurice GM, Orrell C, Gray G, Bangsberg DR. Understanding the role of resilience resources, antiretroviral therapy initiation, and HIV-1 RNA suppression among people living with HIV in South Africa: a prospective cohort study. AIDS 2019; 33 Suppl 1:S71-S79. [PMID: 31397725 PMCID: PMC6712569 DOI: 10.1097/qad.0000000000002175] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [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: 01/17/2023]
Abstract
OBJECTIVE Failure to initiate antiretroviral therapy (ART) and achieve virologic suppression are significant barriers to the United Nations 90-90-90 goals. Identifying resilience resources, or modifiable strength-based factors, among people living with HIV is critical for successful HIV treatment and prevention. DESIGN Prospective cohort study. METHODS From July 2014 to July 2015, 500 adults presenting for voluntary counseling and HIV testing who were diagnosed with HIV and were ART-eligible in South Africa (Soweto and Gugulethu) were enrolled and surveyed. Logistic regression models assessed resilience-related predictors of ART initiation within 6 months of voluntary counseling and HIV testing for HIV, and HIV-1 plasma RNA suppression within 9 months, adjusting for sociodemographic factors. RESULTS Within 6 months, 62% initiated ART, and within 9 months, 25% had evidence of an undetectable HIV-1 plasma RNA (<50 copies/ml). Participants who initiated ART relied less on social support from friends [adjusted odds ratio (aOR) 0.94, 95% confidence interval (CI): 0.89-0.99], coped using self-distraction (aOR 1.05, 95% CI: 1.00-1.10) and avoided coping through substance use (aOR 0.79, 95% CI: 0.65-0.97), as compared with participants who did not initiate ART. Those who achieved plasma RNA suppression relied more on social support from a significant other/partner (aOR 1.04, 95% CI: 1.02-1.07), used positive religious coping (aOR 1.03, 95% CI: 1.00-1.07), and were less likely to engage in denial coping (aOR 0.84, 95% CI: 0.77-0.92), compared with those who initiated ART but did not achieve plasma RNA suppression. CONCLUSION Interventions optimizing resilience resources and decreasing maladaptive coping strategies (e.g., substance use, denial) may present a feasible approach to maximizing ART-based HIV treatment strategies among South African people living with HIV.
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Affiliation(s)
- Ingrid T. Katz
- Department of Medicine, Brigham and Women’s Hospital
- Harvard Medical School
- Massachusetts General Hospital Center for Global Health, Boston
- Harvard Global Health Institute, Cambridge, Massachusetts
| | | | - Janan J. Dietrich
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | | | - Dominick Leone
- Department of Medicine, Brigham and Women’s Hospital
- Brigham and Women’s Hospital, Channing Division of Network Medicine, Boston, Massachusetts
| | | | - Valerie A. Earnshaw
- Department of Human Development and Family Sciences, University of Delaware, Newark, Delaware, USA
| | - Ingrid Courtney
- Desmond Tutu HIV Foundation, University of Cape Town Medical School, Cape Town, South Africa
| | - Gugu Tshabalala
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Garrett M. Fitzmaurice
- Department of Medicine, Brigham and Women’s Hospital
- Harvard Medical School
- Department of Biostatistics, Harvard School of Public Health, Boston
- Laboratory for Psychiatric Biostatistics, McLean Hospital, Belmont, Massachusetts, USA
| | - Catherine Orrell
- Desmond Tutu HIV Foundation, University of Cape Town Medical School, Cape Town, South Africa
| | - Glenda Gray
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Office of the President, South African Medical Research Council, Western Cape, South Africa
| | - David R. Bangsberg
- Oregon Health & Science University-Portland State University School of Public Health, Portland, Oregon, USA
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26
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Magidson JF, Iyer HS, Regenauer KS, Grelotti DJ, Dietrich JJ, Courtney I, Tshabalala G, Orrell C, Gray GE, Bangsberg DR, Katz IT. Recreational ART use among individuals living with HIV/AIDS in South Africa: Examining longitudinal ART initiation and viral suppression. Drug Alcohol Depend 2019; 198:192-198. [PMID: 30953938 PMCID: PMC6644059 DOI: 10.1016/j.drugalcdep.2019.02.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 01/30/2019] [Accepted: 02/03/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND South Africa has the highest number of people living with HIV (PLWH) and one of the largest antiretroviral therapy (ART) programs globally. High rates of substance use comorbidity exist, including speculation of recreational ART use (i.e., mixing ART with other illicit drugs). Recreational ART use may affect viral load among PLWH due to ART nonadherence and/or viral resistance; however, prior quantitative research has not examined rates of recreational ART use, nor associations with HIV treatment outcomes longitudinally. METHODS Data were drawn from a prospective, observational cohort study (n = 500) of ART-eligible adults recruited from two HIV voluntary counseling and testing centers in Cape Town, and Johannesburg, South Africa. Multiple logistic regression models assessed recreational ART use as a predictor of ART initiation over six months and viral load suppression over nine months, above and beyond other substance use (binge drinking and illicit drug use). RESULTS Approximately 5% (n = 24) reported recreational ART use, which was less frequent in Cape Town compared to Johannesburg (AOR = 0.025; 95%CI: 0.003-0.19; p < 0.001). Recreational ART use was not significantly associated with ART initiation or viral suppression. Other substance use, but not recreational ART use, was significantly associated with lower odds of ART initiation (AOR = 0.54; 95%CI: 0.33-0.87; p = .01) and viral suppression (AOR = 0.47; 95%CI: 0.25-0.89; p = .02). CONCLUSIONS Recreational ART use was infrequent and not uniquely associated with ART initiation or viral suppression. Findings suggest that comorbid use of other substances is ultimately what may make recreational ART use problematic for ongoing engagement in care and viral suppression.
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Affiliation(s)
- Jessica F Magidson
- Department of Psychology, University of Maryland, College Park, 4095 Campus Drive, College Park, MD, USA.
| | - Hari S Iyer
- Harvard T. H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA, USA.
| | - Kristen S Regenauer
- Department of Psychiatry, Massachusetts General Hospital, One Bowdoin Square, Boston, MA, USA.
| | - David J Grelotti
- Department of Psychiatry, University of California San Diego, La Jolla, CA, USA.
| | - Janan J Dietrich
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa.
| | - Ingrid Courtney
- Department of Medicine and the Institute of Infectious Disease and Molecular Medicine, Desmond Tutu HIV Foundation, University of Cape Town, Cape Town, ZA, South Africa.
| | - Gugu Tshabalala
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa.
| | - Catherine Orrell
- Department of Medicine and the Institute of Infectious Disease and Molecular Medicine, Desmond Tutu HIV Foundation, University of Cape Town, Cape Town, ZA, South Africa.
| | - Glenda E Gray
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa; Office of the President, South African Medical Research Council, Western Cape, ZA, South Africa.
| | - David R Bangsberg
- Oregon Health & Science University-Portland State University School of Public Health, Portland, OR, USA.
| | - Ingrid T Katz
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA; Massachusetts General Hospital Center for Global Health, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
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Haberer JE, Bwana BM, Orrell C, Asiimwe S, Amanyire G, Musinguzi N, Siedner MJ, Matthews LT, Tsai AC, Katz IT, Bell K, Kembabazi A, Mugisha S, Kibirige V, Cross A, Kelly N, Hedt‐Gauthier B, Bangsberg DR. ART adherence and viral suppression are high among most non-pregnant individuals with early-stage, asymptomatic HIV infection: an observational study from Uganda and South Africa. J Int AIDS Soc 2019; 22:e25232. [PMID: 30746898 PMCID: PMC6371013 DOI: 10.1002/jia2.25232] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [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: 09/10/2018] [Accepted: 12/19/2018] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION The success of universal antiretroviral therapy (ART) access and aspirations for an AIDS-free generation depend on high adherence in individuals initiating ART during early-stage HIV infection; however, adherence may be difficult in the absence of illness and associated support. METHODS From March 2015 to October 2017, we prospectively observed three groups initiating ART in routine care in Uganda and South Africa: men and non-pregnant women with early-stage HIV infection (CD4 > 350 cells/μL), pregnant women with early-stage HIV infection and men and non-pregnant women with late-stage HIV infection (CD4 < 200 cells/μL). Socio-behavioural questionnaires were administered and viral loads were performed at 0, 6 and 12 months. Adherence was monitored electronically. RESULTS Adherence data were available for 869 participants: 322 (37%) early/non-pregnant, 199 (23%) early/pregnant and 348 (40%) late/non-pregnant participants. In Uganda, median adherence was 89% (interquartile range 74 to 96) and viral suppression was 90% at 12 months; neither differed among groups (p > 0.72). In South Africa, median adherence was higher in early/non-pregnant versus early/pregnant or late/non-pregnant participants (76%, 37%, 52%; p < 0.001), with similar trends in viral suppression (86%, 51%, 79%; p < 0.001). Among early/non-pregnant individuals in Uganda, adherence was higher with increasing age and lower with structural barriers; whereas in South Africa, adherence was higher with regular income, higher perceived stigma and use of other medications, but lower with maladaptive coping and cigarette smoking. DISCUSSION ART adherence among non-pregnant individuals with early-stage infection is as high or higher than with late-stage initiation, supporting universal access to ART. Challenges remain for some pregnant women and individuals with late-stage infection in South Africa and highlight the need for differentiated care delivery.
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Affiliation(s)
- Jessica E Haberer
- Massachusetts General Hospital Center for Global HealthBostonMAUSA
- Harvard Medical SchoolBostonMAUSA
| | - Bosco M Bwana
- Mbarara University of Science and TechnologyMbararaUganda
- Global Health CollaborativeMbararaUganda
| | - Catherine Orrell
- Desmond Tutu HIV FoundationCape TownSouth Africa
- University of Cape TownCape TownSouth Africa
| | - Stephen Asiimwe
- Global Health CollaborativeMbararaUganda
- Kabwohe Clinical Research CentreKabwoheUganda
| | - Gideon Amanyire
- Global Health CollaborativeMbararaUganda
- Makerere University Joint AIDS ProgramKampalaUganda
- Africa Health Research InstituteDurbanSouth Africa
| | | | - Mark J Siedner
- Massachusetts General Hospital Center for Global HealthBostonMAUSA
- Harvard Medical SchoolBostonMAUSA
- Africa Health Research InstituteDurbanSouth Africa
| | - Lynn T Matthews
- Massachusetts General Hospital Center for Global HealthBostonMAUSA
- Harvard Medical SchoolBostonMAUSA
| | - Alexander C Tsai
- Massachusetts General Hospital Center for Global HealthBostonMAUSA
- Harvard Medical SchoolBostonMAUSA
| | - Ingrid T Katz
- Harvard Medical SchoolBostonMAUSA
- Brigham and Women's HospitalBostonMAUSA
| | - Kathleen Bell
- Massachusetts General Hospital Center for Global HealthBostonMAUSA
| | | | | | | | - Anna Cross
- Desmond Tutu HIV FoundationCape TownSouth Africa
| | - Nicola Kelly
- Desmond Tutu HIV FoundationCape TownSouth Africa
| | - Bethany Hedt‐Gauthier
- Massachusetts General Hospital Center for Global HealthBostonMAUSA
- Harvard Medical SchoolBostonMAUSA
| | - David R Bangsberg
- Oregon Health & Science University‐Portland State University School of Public HealthPortlandORUSA
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Chan BT, Maughan-Brown BG, Bogart LM, Earnshaw VA, Tshabalala G, Courtney I, Dietrich JJ, Orrell C, Gray GE, Bangsberg DR, Tsai AC, Katz IT. Trajectories of HIV-related internalized stigma and disclosure concerns among ART initiators and non-initiators in South Africa. Stigma Health 2019; 4:433-441. [PMID: 31788556 DOI: 10.1037/sah0000159] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Background HIV-related stigma among people living with HIV (PLHIV) is associated with worse health outcomes. We used longitudinal data from a multi-site cohort in South Africa to assess changes over time in stigma after HIV diagnosis and determine whether antiretroviral therapy (ART) initiation is associated with stigma reduction. Methods We administered the Internalized AIDS-Related Stigma Scale (IARSS, a six-item dichotomous scale questionnaire) at baseline, three months, and six months to newly diagnosed ART-eligible participants between 2014-2015. A confirmatory factor analysis indicated that the IARSS contained a four-item internalized stigma factor (α=0.80) and a two-item disclosure concerns factor (α=0.75). We fitted multiple logistic regression models specifying internalized stigma/disclosure concerns at six months as the outcome and ART initiation as the predictor of interest. Results Of the 500 participants (187 men and 313 women) enrolled, 308 (62%) initiated ART. Internalized stigma declined among people entering care (mean score, 1.0 to 0.7, p<0.01); however, disclosure concerns remained unchanged (percentage endorsing either disclosure concern item, 78% to 77%, p=0.23). These findings were similar between ART initiators and non-initiators. We estimated a statistically significant positive association between ART initiation and disclosure concerns at six months (OR=1.88; 95% CI, 1.20-2.94) but not between ART initiation and internalized stigma at six months (OR=1.15; 95% CI, 0.75-1.78). Conclusions Among ART-eligible South African PLHIV entering into HIV care, internalized stigma modestly declined over time but disclosure concerns persisted. PLHIV who initiated ART were more likely to have persistent disclosure concerns over time as compared with those who did not start ART.
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Affiliation(s)
- Brian T Chan
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Brendan G Maughan-Brown
- Southern Africa Labour and Development Research Unit, University of Cape Town, Rondebosch, Cape Town, 7701, South Africa
| | | | - Valerie A Earnshaw
- Department of Human Development and Family Sciences, University of Delaware, Newark, DE, USA
| | - Gugulethu Tshabalala
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Ingrid Courtney
- Desmond Tutu HIV Foundation, University of Cape Town Medical School, Cape Town, South Africa
| | - Janan J Dietrich
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Catherine Orrell
- Desmond Tutu HIV Foundation, University of Cape Town Medical School, Cape Town, South Africa
| | - Glenda E Gray
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,South African Medical Research Council, Cape Town 7500, South Africa
| | - David R Bangsberg
- Oregon Health & Science University-Portland State University School of Public Health, Portland, Oregon, United States of America
| | - Alexander C Tsai
- Harvard Medical School, Boston, MA, USA.,MGH Global Health, Massachusetts General Hospital, Boston, MA, USA.,Chester M. Pierce, MD Division of Global Psychiatry, Massachusetts General Hospital, Boston, MA, USA.,Mbarara University of Science and Technology, Mbarara, Uganda
| | - Ingrid T Katz
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,MGH Global Health, Massachusetts General Hospital, Boston, MA, USA.,Harvard Global Health Institute, Cambridge, MA, USA
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Earnshaw VA, Bogart LM, Laurenceau J, Chan BT, Maughan‐Brown BG, Dietrich JJ, Courtney I, Tshabalala G, Orrell C, Gray GE, Bangsberg DR, Katz IT. Internalized HIV stigma, ART initiation and HIV-1 RNA suppression in South Africa: exploring avoidant coping as a longitudinal mediator. J Int AIDS Soc 2018; 21:e25198. [PMID: 30362662 PMCID: PMC6202800 DOI: 10.1002/jia2.25198] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [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: 05/29/2018] [Accepted: 10/02/2018] [Indexed: 12/29/2022] Open
Abstract
INTRODUCTION Cross-sectional evidence suggests that internalized HIV stigma is associated with lower likelihoods of antiretroviral therapy (ART) initiation and HIV-1 RNA suppression among people living with HIV (PLWH). This study examined these associations with longitudinal data spanning the first nine months following HIV diagnosis and explored whether avoidant coping mediates these associations. METHODS Longitudinal data were collected from 398 South African PLWH recruited from testing centres in 2014 to 2015. Self-report data, including internalized stigma and avoidant coping (denying and distracting oneself from stressors), were collected one week and three months following HIV diagnosis. ART initiation at six months and HIV-1 RNA at nine months were extracted from the South Africa National Health Laboratory Service database. Two path analyses were estimated, one testing associations between internalized stigma, avoidant coping and ART initiation, and the other testing associations between internalized stigma, avoidant coping and HIV-1 RNA suppression. RESULTS Participants were 36 years old, on average, and 63% identified as female, 18% as Zulu and 65% as Xhosa. The two path models fit the data well (ART initiation outcome: X2 (7) = 8.14, p = 0.32; root mean square error of approximation (RMSEA) = 0.02; comparative fit index (CFI) = 0.92; HIV-1 RNA suppression outcome: X2 (7) = 6.58, p = 0.47; RMSEA = 0.00; CFI = 1.00). In both models, internalized stigma one week after diagnosis was associated with avoidant coping at three months, controlling for avoidant coping at one week. In turn, avoidant coping at three months was associated with lower likelihood of ART initiation at six months in the first model and lower likelihood of HIV-1 RNA suppression at nine months in the second model. Significant indirect effects were observed between internalized stigma with ART non-initiation and unsuppressed HIV-1 RNA via the mediator of avoidant coping. CONCLUSIONS Internalized stigma experienced soon after HIV diagnosis predicted lower likelihood of ART initiation and HIV-1 RNA suppression over the first year following HIV diagnosis. Avoidant coping played a role in these associations, suggesting that PLWH who internalize stigma engage in greater avoidant coping, which in turn worsens medication- and health-related outcomes. Interventions are needed to address internalized stigma and avoidant coping soon after HIV diagnosis to enhance treatment efforts during the first year after HIV diagnosis.
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Affiliation(s)
- Valerie A Earnshaw
- Department of Human Development and Family SciencesUniversity of DelawareNewarkDEUSA
| | | | | | - Brian T Chan
- Department of MedicineBrigham and Women's HospitalBostonMAUSA
- Harvard Medical SchoolBostonMAUSA
| | - Brendan G Maughan‐Brown
- Southern Africa Labour and Development Research UnitUniversity of Cape TownRondeboschCape TownSouth Africa
| | - Janan J Dietrich
- Perinatal HIV Research UnitFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Ingrid Courtney
- Desmond Tutu HIV Centre, IDM and Department of MedicineUniversity of Cape TownCape TownSouth Africa
| | - Gugulethu Tshabalala
- Perinatal HIV Research UnitFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Catherine Orrell
- Desmond Tutu HIV Centre, IDM and Department of MedicineUniversity of Cape TownCape TownSouth Africa
| | - Glenda E Gray
- Perinatal HIV Research UnitFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
- South African Medical Research CouncilCape TownSouth Africa
| | - David R Bangsberg
- Oregon Health & Science University‐Portland State University School of Public HealthPortlandORUSA
| | - Ingrid T Katz
- Department of MedicineBrigham and Women's HospitalBostonMAUSA
- Harvard Medical SchoolBostonMAUSA
- Center for Global HealthMassachusetts General HospitalBostonMAUSA
- Harvard Global Health InstituteCambridgeMAUSA
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30
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Earnshaw VA, Bogart LM, Courtney I, Zanoni H, Bangsberg DR, Orrell C, Goggin K, Katz IT. Exploring Treatment Needs and Expectations for People Living with HIV in South Africa: A Qualitative Study. AIDS Behav 2018; 22:2543-2552. [PMID: 29619585 DOI: 10.1007/s10461-018-2101-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
The UNAIDS 90-90-90 treatment targets aim to dramatically increase the number of people who initiate antiretroviral therapy (ART) by 2020. Greater understanding of barriers to ART initiation in high prevalence countries like South Africa is critical. Qualitative semi-structured interviews were conducted with 30 participants in Gugulethu Township, South Africa, including 10 healthcare providers and 20 people living with HIV (PLWH) who did not initiate ART. Interviews explored barriers to ART initiation and acceptability of theory-based intervention strategies to optimize ART initiation. An inductive content analytic approach was applied to the data. Consistent with the Theory of Triadic Influence, barriers to ART initiation were identified at the individual, social, and structural levels. Results suggested high acceptability for intervention strategies involving trained HIV-positive peers among South African PLWH and healthcare providers. Research is needed to evaluate their feasibility and efficacy in high HIV prevalence countries.
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Affiliation(s)
- Ingrid T Katz
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Center for Global Health, Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
| | - Peter Ehrenkranz
- Global Development, Bill & Melinda Gates Foundation, Seattle, Washington
| | - Wafaa El-Sadr
- ICAP at Columbia University, New York, New York
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
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Markt SC, Tang T, Cronin AM, Katz IT, Howitt BE, Horowitz NS, Lee LJ, Wright AA. Insurance status and cancer treatment mediate the association between race/ethnicity and cervical cancer survival. PLoS One 2018; 13:e0193047. [PMID: 29447263 PMCID: PMC5814056 DOI: 10.1371/journal.pone.0193047] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [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] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 02/02/2018] [Indexed: 11/18/2022] Open
Abstract
Cervical cancer outcomes remain poor among disadvantaged populations, including ethnic minorities, low-income, and underinsured women. The aim of this study was to evaluate the mechanisms that underlie the observed association between race/ethnicity and cervical cancer survival. We identified 13,698 women, ages 21 to 64 years, diagnosed with stages I-III primary cervical cancer between 2007-2013 in Surveillance, Epidemiology, and End Results (SEER). Multivariable Cox proportional hazards regression models evaluated associations between race/ethnicity (Non-Hispanic White, Non-Hispanic Black, Hispanic, Other) and cervical cancer-specific mortality. We conducted mediation analysis to calculate the mediation proportion and its 95% confidence interval. Non-Hispanic black women had an increased risk of cervical cancer-specific mortality (HR: 1.23, 95% CI: 1.08-1.39), and Hispanic women a decreased risk of dying from their disease (HR: 0.82, 95% CI: 0.72-0.93), compared with non-Hispanic white. The estimated proportion of excess cervical cancer mortality for non-Hispanic black women relative to non-Hispanic white women that was mediated by insurance was 18.6% and by treatment was 47.2%. Furthermore, non-Hispanic black women were more likely to receive radiation and less likely to receive surgery for early-stage disease. In this population-based study we found that some of the excess cervical cancer-specific mortality for non-Hispanic black women is mediated by factors such as insurance status and treatment. These findings suggest that enhancing existing insurance coverage and ensuring equal and adequate treatment in all women may be a key strategy for improving cervical cancer outcomes.
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Affiliation(s)
- Sarah C. Markt
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Tianyu Tang
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Angel M. Cronin
- Dana-Farber Cancer Institute, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
| | - Ingrid T. Katz
- Harvard Medical School, Boston, Massachusetts, United States of America
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
- Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Brooke E. Howitt
- Harvard Medical School, Boston, Massachusetts, United States of America
- Department of Pathology, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
| | - Neil S. Horowitz
- Dana-Farber Cancer Institute, Boston, Massachusetts, United States of America
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
- Department of Obstetrics and Gynecology, Division Gynecologic Oncology, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
| | - Larissa J. Lee
- Dana-Farber Cancer Institute, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
- Department of Radiation Oncology, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
| | - Alexi A. Wright
- Dana-Farber Cancer Institute, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
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Affiliation(s)
- Alexi A Wright
- Drs. Wright and Katz are national correspondents for the Journal
| | - Ingrid T Katz
- Drs. Wright and Katz are national correspondents for the Journal
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Katz IT, Kaplan R, Fitzmaurice G, Leone D, Bangsberg DR, Bekker LG, Orrell C. Treatment guidelines and early loss from care for people living with HIV in Cape Town, South Africa: A retrospective cohort study. PLoS Med 2017; 14:e1002434. [PMID: 29136014 PMCID: PMC5685472 DOI: 10.1371/journal.pmed.1002434] [Citation(s) in RCA: 14] [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: 06/09/2017] [Accepted: 10/10/2017] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND South Africa has undergone multiple expansions in antiretroviral therapy (ART) eligibility from an initial CD4+ threshold of ≤200 cells/μl to providing ART for all people living with HIV (PLWH) as of September 2016. We evaluated the association of programmatic changes in ART eligibility with loss from care, both prior to ART initiation and within the first 16 weeks of starting treatment, during a period of programmatic expansion to ART treatment at CD4+ ≤ 350 cells/μl. METHODS AND FINDINGS We performed a retrospective cohort study of 4,025 treatment-eligible, non-pregnant PLWH accessing care in a community health center in Gugulethu Township affiliated with the Desmond Tutu HIV Centre in Cape Town. The median age of participants was 34 years (IQR 28-41 years), almost 62% were female, and the median CD4+ count was 173 cells/μl (IQR 92-254 cells/μl). Participants were stratified into 2 cohorts: an early cohort, enrolled into care at the health center from 1 January 2009 to 31 August 2011, when guidelines mandated that ART initiation required CD4+ ≤ 200 cells/μl, pregnancy, advanced clinical symptoms (World Health Organization [WHO] stage 4), or comorbidity (active tuberculosis); and a later cohort, enrolled into care from 1 September 2011 to 31 December 2013, when the treatment threshold had been expanded to CD4+ ≤ 350 cells/μl. Demographic and clinical factors were compared before and after the policy change using chi-squared tests to identify potentially confounding covariates, and logistic regression models were used to estimate the risk of pre-treatment (pre-ART) loss from care and early loss within the first 16 weeks on treatment, adjusting for age, baseline CD4+, and WHO stage. Compared with participants in the later cohort, participants in the earlier cohort had significantly more advanced disease: median CD4+ 146 cells/μl versus 214 cells/μl (p < 0.001), 61.1% WHO stage 3/4 disease versus 42.8% (p < 0.001), and pre-ART mortality of 34.2% versus 16.7% (p < 0.001). In total, 385 ART-eligible PLWH (9.6%) failed to initiate ART, of whom 25.7% died before ever starting treatment. Of the 3,640 people who started treatment, 58 (1.6%) died within the first 16 weeks in care, and an additional 644 (17.7%) were lost from care within 16 weeks of starting ART. PLWH who did start treatment in the later cohort were significantly more likely to discontinue care in <16 weeks (19.8% versus 15.8%, p = 0.002). After controlling for baseline CD4+, WHO stage, and age, this effect remained significant (adjusted odds ratio [aOR] = 1.30, 95% CI 1.09-1.55). As such, it remains unclear if early attrition from care was due to a "healthy cohort" effect or to overcrowding as programs expanded to accommodate the broader guidelines for treatment. Our findings were limited by a lack of generalizability (given that these data were from a single high-volume site where testing and treatment were available) and an inability to formally investigate the effect of crowding on the main outcome. CONCLUSIONS Over one-quarter of this ART-eligible cohort did not achieve the long-term benefits of treatment due to early mortality, ART non-initiation, or early ART discontinuation. Those who started treatment in the later cohort appeared to be more likely to discontinue care early, and this outcome appeared to be independent of CD4+ count or WHO stage. Future interventions should focus on those most at risk for early loss from care as programs continue to expand in South Africa.
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Affiliation(s)
- Ingrid T. Katz
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
- Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
- * E-mail:
| | - Richard Kaplan
- Desmond Tutu HIV Centre, University of Cape Town Medical School, Cape Town, South Africa
| | - Garrett Fitzmaurice
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
- Laboratory for Psychiatric Biostatistics, McLean Hospital, Belmont, Massachusetts, United States of America
| | - Dominick Leone
- Ragon Institute of MGH, MIT and Harvard, Boston, Massachusetts, United States of America
| | - David R. Bangsberg
- Oregon Health & Science University–Portland State University School of Public Health, Portland, Oregon, United States of America
| | - Linda-Gail Bekker
- Desmond Tutu HIV Centre, University of Cape Town Medical School, Cape Town, South Africa
| | - Catherine Orrell
- Desmond Tutu HIV Centre, University of Cape Town Medical School, Cape Town, South Africa
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Bor J, Ahmed S, Fox MP, Rosen S, Meyer-Rath G, Katz IT, Tanser F, Pillay D, Bärnighausen T. Effect of eliminating CD4-count thresholds on HIV treatment initiation in South Africa: An empirical modeling study. PLoS One 2017; 12:e0178249. [PMID: 28617805 PMCID: PMC5472329 DOI: 10.1371/journal.pone.0178249] [Citation(s) in RCA: 19] [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: 09/21/2016] [Accepted: 04/21/2017] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND The World Health Organization recommends initiating antiretroviral therapy (ART) regardless of CD4 count. We assessed the effect of ART eligibility on treatment uptake and simulated the impact of WHO's recommendations in South Africa. METHODS We conducted an empirical analysis of cohort data using a regression discontinuity design, and then used this model for policy simulation. We enrolled all patients (n = 19,279) diagnosed with HIV between August 2011 and December 2013 in the Hlabisa HIV Treatment and Care Programme in rural South Africa. Patients were ART-eligible with CD4<350 cells/mm3 or Stage III/IV illness. We estimated: (1) distribution of first CD4 counts in 2013; (2) probability of initiating ART ≤6 months of HIV diagnosis under existing criteria at each CD4 count; (3) probability of initiating ART by CD4 count if thresholds were eliminated; and (4) number of expected new initiators if South Africa eliminates thresholds. FINDINGS In 2013, 38.9% of patients diagnosed had a CD4 count ≥500. 8.0% of these patients initiated even without eligible CD4 counts. If CD4 criteria were eliminated, we project that an additional 19.2% of patients with CD4 ≥500 would initiate ART; 72.8% would not initiate ART despite being eligible. Eliminating CD4 criteria would increase the number starting ART by 26.7%. If these numbers hold nationally, this would represent an additional 164,000 initiators per year, a 5.2% increase in patients receiving ART and 5.3% increase in programme costs. CONCLUSIONS Removing CD4 criteria alone will modestly increase timely uptake of ART. However, our results suggest the majority of newly-eligible patients will not initiate. Improved testing, linkage, and initiation procedures are needed to achieve 90-90-90 targets.
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Affiliation(s)
- Jacob Bor
- Department of Global Health, Boston University School of Public Health, Boston, MA, United States of America
- Africa Health Research Institute, Somkhele and Durban, South Africa
- Health Economics and Epidemiology Research Office, University of Witwatersrand, Johannesburg, South Africa
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, United States of America
| | - Shahira Ahmed
- Department of Global Health, Boston University School of Public Health, Boston, MA, United States of America
- Health Economics and Epidemiology Research Office, University of Witwatersrand, Johannesburg, South Africa
| | - Matthew P. Fox
- Department of Global Health, Boston University School of Public Health, Boston, MA, United States of America
- Health Economics and Epidemiology Research Office, University of Witwatersrand, Johannesburg, South Africa
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, United States of America
| | - Sydney Rosen
- Department of Global Health, Boston University School of Public Health, Boston, MA, United States of America
- Health Economics and Epidemiology Research Office, University of Witwatersrand, Johannesburg, South Africa
| | - Gesine Meyer-Rath
- Department of Global Health, Boston University School of Public Health, Boston, MA, United States of America
- Health Economics and Epidemiology Research Office, University of Witwatersrand, Johannesburg, South Africa
| | - Ingrid T. Katz
- Division of Women’s Health, Brigham and Women’s Hospital, Boston, MA, United States
- Center for Global Health, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
| | - Frank Tanser
- Africa Health Research Institute, Somkhele and Durban, South Africa
| | - Deenan Pillay
- Africa Health Research Institute, Somkhele and Durban, South Africa
- Department of Virology, University College London, London, United Kingdom
| | - Till Bärnighausen
- Africa Health Research Institute, Somkhele and Durban, South Africa
- Heidelberg Institute of Public Health, University of Heidelberg, Heidelberg, Germany
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, United States of America
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Johnson KL, Lin MY, Cabral H, Kazis LE, Katz IT. Variation in Human Papillomavirus Vaccine Uptake and Acceptability Between Female and Male Adolescents and Their Caregivers. J Community Health 2017; 42:522-532. [PMID: 27778139 PMCID: PMC5403619 DOI: 10.1007/s10900-016-0284-5|] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/22/2023]
Abstract
HPV vaccination coverage is suboptimal. Previous research largely focused on vaccinating girls. This study aimed to identify factors associated with HPV vaccination among male and female adolescents. We conducted secondary analyses using the National Immunization Survey-Teen. We specified parallel logistic models to examine associations of adolescent, caregiver, and provider characteristics with vaccination status among boys and girls. The primary outcome was HPV vaccination status defined as unvaccinated, initiated, or completed. Additionally, we analyzed caregivers' intent to initiate or complete the three-dose series. The vaccination completion rate was 26 %. Among teens aged 13-17 years, 19 % initiated, but did not complete the vaccine. Additionally, 14 % of males completed the 3-dose series as compared to 38 % of females. Vaccination rates were higher among teens receiving a provider recommendation [girls: adjusted odds ratio (AOR) = 3.33, 95 % confidence interval (CI) (2.44, 4.55); boys: AOR = 10.0, 95 % CI (7.69, 12.5)]. Moreover, provider recommendation was associated with caregivers' intent to initiate vaccination [girls: AOR = 2.32, 95 % CI (1.77, 3.02); boys: AOR = 2.76, 95 % CI (2.22, 3.43)]. Other associations differed by gender. Higher vaccine initiation rates were associated with younger age and residing in the mid-west for girls and racial/ethnic minority and eligibility for the "Vaccine for Children" program for boys. Provider recommendation for vaccination was the strongest predictor for both genders; however, it is insufficient to achieve high coverage rates, especially among boys. Factors associated with HPV vaccination were different for males and females. These findings suggest providers should consider gender bias with regard to HPV vaccination.
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Affiliation(s)
- Kristin L Johnson
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA.
- John Snow Inc., Boston, MA, USA.
| | - Meng-Yun Lin
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, USA
| | - Howard Cabral
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Lewis E Kazis
- Center for the Assessment of Pharmaceutical Practices (CAPP), Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, USA
| | - Ingrid T Katz
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Center for Global Health, Massachusetts General Hospital, Boston, MA, USA
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Katz IT, Maughan-Brown B. Improved life expectancy of people living with HIV: who is left behind? Lancet HIV 2017; 4:e324-e326. [PMID: 28501496 PMCID: PMC5828160 DOI: 10.1016/s2352-3018(17)30086-3] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Revised: 03/23/2017] [Accepted: 04/12/2017] [Indexed: 01/06/2023]
Affiliation(s)
- Ingrid T Katz
- Department of Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA; Massachusetts General Hospital, Center for Global Health, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
| | - Brendan Maughan-Brown
- Southern Africa Labour and Development Research Unit, University of Cape Town, South Africa
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Affiliation(s)
- Ingrid T Katz
- From the Division of Women's Health, Brigham and Women's Hospital (I.T.K.), the Center for Global Health, Massachusetts General Hospital (I.T.K.), Harvard Medical School (I.T.K., A.A.W.), and the Dana-Farber Cancer Institute (A.A.W.) - all in Boston
| | - Alexi A Wright
- From the Division of Women's Health, Brigham and Women's Hospital (I.T.K.), the Center for Global Health, Massachusetts General Hospital (I.T.K.), Harvard Medical School (I.T.K., A.A.W.), and the Dana-Farber Cancer Institute (A.A.W.) - all in Boston
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Abstract
Recent recommendations by the World Health Organization support treatment for all people living with HIV (PLWH) globally to be initiated at the point of testing. While there has been marked success in efforts to identify and expand treatment for PLWH throughout sub-Saharan Africa, the goal of universal treatment may prove challenging to achieve. The pre-ART phase of the care cascade from HIV testing to HIV treatment initiation includes several social and structural barriers. One such barrier is antiretroviral therapy (ART) treatment refusal, a phenomenon in which HIV-infected individuals choose not to start treatment upon learning their ART eligibility. Our goal is to provide further understanding of why treatment-eligible adults may choose to present for HIV testing but not initiate ART when indicated. In this article, we will discuss factors driving pre-ART loss and present a framework for understanding the impact of decision-making on early losses in the care cascade, with a focus on ART refusal.
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Affiliation(s)
- Ingrid T Katz
- Division of Women's Health, Department of Medicine, Brigham and Women's Hospital, 1620 Tremont St, Boston, MA, 02120, USA. .,Harvard Medical School, Boston, MA, USA. .,Massachusetts General Hospital Center for Global Health, Boston, MA, USA.
| | - David R Bangsberg
- Harvard Medical School, Boston, MA, USA.,Massachusetts General Hospital Center for Global Health, Boston, MA, USA
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Downs JA, Mathad JS, Reif LK, McNairy ML, Celum C, Boutin-Foster C, Deschamps MM, Gupta A, Hokororo A, Katz IT, Konopasek L, Nelson R, Riviere C, Glimcher LH, Fitzgerald DW. The ripple effect: why promoting female leadership in global health matters. Public Health Action 2016; 6:210-211. [PMID: 28123954 DOI: 10.5588/pha.16.0072] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [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: 08/23/2016] [Accepted: 10/12/2016] [Indexed: 11/10/2022] Open
Abstract
Leadership positions in global health are greatly skewed toward men; the imbalance is more pronounced in low- and middle-income countries (LMICs). The under-representation of women in leadership is a threat to gender equality, and also impacts the improvement of women's health outcomes globally. In this perspectives piece, we assert that the promotion and retention of women in global health leadership has a ripple effect that can achieve improvement in global health outcomes. We present pragmatic, actionable solutions to promote and retain female global health leaders in this field.
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Affiliation(s)
- J A Downs
- Center for Global Health, Department of Medicine, Weill Cornell Medical College, New York, New York, USA ; Bugando Medical Centre and Catholic University of Health and Allied Sciences, Mwanza, Tanzania
| | - J S Mathad
- Center for Global Health, Department of Medicine, Weill Cornell Medical College, New York, New York, USA ; Clinical Trials Unit, Byramjee Jeejeebhoy Medical College, Pune, India
| | - L K Reif
- Center for Global Health, Department of Medicine, Weill Cornell Medical College, New York, New York, USA
| | - M L McNairy
- Center for Global Health, Department of Medicine, Weill Cornell Medical College, New York, New York, USA
| | - C Celum
- International Clinical Research Center, University of Washington, Seattle, Washington, USA
| | - C Boutin-Foster
- Center for Global Health, Department of Medicine, Weill Cornell Medical College, New York, New York, USA
| | - M M Deschamps
- Groupe Haïtien d'Etude du Sarcome de Kaposi et des Infections Opportunistes, Port-au-Prince, Haïti
| | - A Gupta
- Clinical Trials Unit, Byramjee Jeejeebhoy Medical College, Pune, India ; Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - A Hokororo
- Bugando Medical Centre and Catholic University of Health and Allied Sciences, Mwanza, Tanzania
| | - I T Katz
- Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts, USA ; Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - L Konopasek
- Center for Global Health, Department of Medicine, Weill Cornell Medical College, New York, New York, USA
| | - R Nelson
- Department of Anthropology, Skidmore College, Saratoga Springs, New York, USA
| | - C Riviere
- Groupe Haïtien d'Etude du Sarcome de Kaposi et des Infections Opportunistes, Port-au-Prince, Haïti
| | - L H Glimcher
- Center for Global Health, Department of Medicine, Weill Cornell Medical College, New York, New York, USA
| | - D W Fitzgerald
- Center for Global Health, Department of Medicine, Weill Cornell Medical College, New York, New York, USA
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Katz IT, Butler LM, Crankshaw TL, Wright AA, Bramhill K, Leone DA, Giddy J, Mould S. Cervical Abnormalities in South African Women Living With HIV With High Screening and Referral Rates. J Glob Oncol 2016; 2:375-380. [PMID: 28717723 PMCID: PMC5493244 DOI: 10.1200/jgo.2015.002469] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
PURPOSE To determine the prevalence of screening, cervical dysplasia, and malignancy on the basis of histologic diagnoses from colposcopy and large loop excision of the transformation zone among women living with HIV (WLWH) who attended an urban antiretroviral treatment (ART) clinic in KwaZulu-Natal, South Africa. MATERIALS AND METHODS We performed a retrospective cohort study to examine a random sample of 462 WLWH during a 5-year period from 2004 to 2009. Women on ART for < 3 months were excluded. Data were abstracted from electronic records and paper charts to assess rates of cervical abnormalities detected on Pap smears as well as time to colposcopy. RESULTS During the study period, 432 women (93.5%) had at least one evaluable Papanicolau test. At baseline, 237 women (54.9%) had an abnormal Papanicolau test, and of these patients, 181 (76.3%) had a Papanicolau test that qualified for further colposcopic evaluation. In addition, 115 women (63.5%) received colposcopy within a median of 39 days from referral. This yielded 74 evaluable histologic samples (64.3%), of which 21.6%, 27.0%, 27.0%, and 1.4% had cervical intraepithelial neoplasia (CIN) 1, CIN2, CIN3, and invasive cervical cancer, respectively. CONCLUSION In a large sample of WLWH who received ART in KwaZulu-Natal, South Africa, where Papanicolau test coverage and rates of referral for colposcopy and large loop excision of the transformation zone were high, > 75% of women with evaluable histologic samples had evidence of cervical dysplasia or malignancy. These findings underscore the importance of routine cervical screening upon entry into HIV care to optimize survival.
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Affiliation(s)
- Ingrid T. Katz
- Ingrid T. Katz and Dominick A. Leone, Brigham and Women’s Hospital; Ingrid T. Katz, Lisa M. Butler, and Alexi A. Wright, Harvard Medical School; Ingrid T. Katz, Massachusetts General Hospital Center for Global Health; Lisa M. Butler, Boston Children’s Hospital; Alexi A. Wright, Dana-Farber Cancer Institute; Dominick A. Leone, Boston University, Boston, MA; Tamaryn L. Crankshaw, University of KwaZulu-Natal, Durban; Janet Giddy, Western Cape Province Department of Health, Cape Town; Sean Mould, R.K. Khan Hospital, Chatsworth, South Africa; and Karen Bramhill, Canadian Red Cross, Ontario, Canada
| | - Lisa M. Butler
- Ingrid T. Katz and Dominick A. Leone, Brigham and Women’s Hospital; Ingrid T. Katz, Lisa M. Butler, and Alexi A. Wright, Harvard Medical School; Ingrid T. Katz, Massachusetts General Hospital Center for Global Health; Lisa M. Butler, Boston Children’s Hospital; Alexi A. Wright, Dana-Farber Cancer Institute; Dominick A. Leone, Boston University, Boston, MA; Tamaryn L. Crankshaw, University of KwaZulu-Natal, Durban; Janet Giddy, Western Cape Province Department of Health, Cape Town; Sean Mould, R.K. Khan Hospital, Chatsworth, South Africa; and Karen Bramhill, Canadian Red Cross, Ontario, Canada
| | - Tamaryn L. Crankshaw
- Ingrid T. Katz and Dominick A. Leone, Brigham and Women’s Hospital; Ingrid T. Katz, Lisa M. Butler, and Alexi A. Wright, Harvard Medical School; Ingrid T. Katz, Massachusetts General Hospital Center for Global Health; Lisa M. Butler, Boston Children’s Hospital; Alexi A. Wright, Dana-Farber Cancer Institute; Dominick A. Leone, Boston University, Boston, MA; Tamaryn L. Crankshaw, University of KwaZulu-Natal, Durban; Janet Giddy, Western Cape Province Department of Health, Cape Town; Sean Mould, R.K. Khan Hospital, Chatsworth, South Africa; and Karen Bramhill, Canadian Red Cross, Ontario, Canada
| | - Alexi A. Wright
- Ingrid T. Katz and Dominick A. Leone, Brigham and Women’s Hospital; Ingrid T. Katz, Lisa M. Butler, and Alexi A. Wright, Harvard Medical School; Ingrid T. Katz, Massachusetts General Hospital Center for Global Health; Lisa M. Butler, Boston Children’s Hospital; Alexi A. Wright, Dana-Farber Cancer Institute; Dominick A. Leone, Boston University, Boston, MA; Tamaryn L. Crankshaw, University of KwaZulu-Natal, Durban; Janet Giddy, Western Cape Province Department of Health, Cape Town; Sean Mould, R.K. Khan Hospital, Chatsworth, South Africa; and Karen Bramhill, Canadian Red Cross, Ontario, Canada
| | - Karen Bramhill
- Ingrid T. Katz and Dominick A. Leone, Brigham and Women’s Hospital; Ingrid T. Katz, Lisa M. Butler, and Alexi A. Wright, Harvard Medical School; Ingrid T. Katz, Massachusetts General Hospital Center for Global Health; Lisa M. Butler, Boston Children’s Hospital; Alexi A. Wright, Dana-Farber Cancer Institute; Dominick A. Leone, Boston University, Boston, MA; Tamaryn L. Crankshaw, University of KwaZulu-Natal, Durban; Janet Giddy, Western Cape Province Department of Health, Cape Town; Sean Mould, R.K. Khan Hospital, Chatsworth, South Africa; and Karen Bramhill, Canadian Red Cross, Ontario, Canada
| | - Dominick A. Leone
- Ingrid T. Katz and Dominick A. Leone, Brigham and Women’s Hospital; Ingrid T. Katz, Lisa M. Butler, and Alexi A. Wright, Harvard Medical School; Ingrid T. Katz, Massachusetts General Hospital Center for Global Health; Lisa M. Butler, Boston Children’s Hospital; Alexi A. Wright, Dana-Farber Cancer Institute; Dominick A. Leone, Boston University, Boston, MA; Tamaryn L. Crankshaw, University of KwaZulu-Natal, Durban; Janet Giddy, Western Cape Province Department of Health, Cape Town; Sean Mould, R.K. Khan Hospital, Chatsworth, South Africa; and Karen Bramhill, Canadian Red Cross, Ontario, Canada
| | - Janet Giddy
- Ingrid T. Katz and Dominick A. Leone, Brigham and Women’s Hospital; Ingrid T. Katz, Lisa M. Butler, and Alexi A. Wright, Harvard Medical School; Ingrid T. Katz, Massachusetts General Hospital Center for Global Health; Lisa M. Butler, Boston Children’s Hospital; Alexi A. Wright, Dana-Farber Cancer Institute; Dominick A. Leone, Boston University, Boston, MA; Tamaryn L. Crankshaw, University of KwaZulu-Natal, Durban; Janet Giddy, Western Cape Province Department of Health, Cape Town; Sean Mould, R.K. Khan Hospital, Chatsworth, South Africa; and Karen Bramhill, Canadian Red Cross, Ontario, Canada
| | - Sean Mould
- Ingrid T. Katz and Dominick A. Leone, Brigham and Women’s Hospital; Ingrid T. Katz, Lisa M. Butler, and Alexi A. Wright, Harvard Medical School; Ingrid T. Katz, Massachusetts General Hospital Center for Global Health; Lisa M. Butler, Boston Children’s Hospital; Alexi A. Wright, Dana-Farber Cancer Institute; Dominick A. Leone, Boston University, Boston, MA; Tamaryn L. Crankshaw, University of KwaZulu-Natal, Durban; Janet Giddy, Western Cape Province Department of Health, Cape Town; Sean Mould, R.K. Khan Hospital, Chatsworth, South Africa; and Karen Bramhill, Canadian Red Cross, Ontario, Canada
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Zanoni BC, Archary M, Buchan S, Katz IT, Haberer JE. Systematic review and meta-analysis of the adolescent HIV continuum of care in South Africa: the Cresting Wave. BMJ Glob Health 2016; 1:e000004. [PMID: 28588949 PMCID: PMC5321340 DOI: 10.1136/bmjgh-2015-000004] [Citation(s) in RCA: 104] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Revised: 06/23/2016] [Accepted: 08/08/2016] [Indexed: 11/03/2022] Open
Abstract
CONTEXT South Africa has the most HIV infections of any country in the world, yet little is known about the adolescent continuum of care from HIV diagnosis through viral suppression. OBJECTIVE To determine the adolescent HIV continuum of care in South Africa. DATA SOURCES We searched PubMed, Google Scholar and online conference proceedings from International AIDS Society (IAS), International AIDS Conference (AIDS) and Conference on Retrovirology and Opportunistic Infections (CROI) from 1 January 2005 to 31 July 2015. DATA EXTRACTION We selected published literature containing South African cohorts and epidemiological data reporting primary data for youth (15-24 years of age) at any stage of the HIV continuum of care (ie, diagnosis, treatment, retention, viral suppression). For the meta-analysis we used six sources for retention in care and nine for viral suppression. RESULTS Among the estimated 867 283 HIV-infected youth from 15 to 24 years old in South Africa in 2013, 14% accessed antiretroviral therapy (ART). Of those on therapy, ∼83% were retained in care and 81% were virally suppressed. Overall, we estimate that 10% of HIV-infected youth in South Africa in 2013 were virally suppressed. LIMITATIONS This analysis relies on published data from large mostly urban South Africa cohorts limiting the generalisability to all adolescents. CONCLUSIONS Despite a large increase in ART programmes in South Africa that have relatively high retention rates and viral suppression rates among HIV-infected youth, only a small percentage are virally suppressed, largely due to low numbers of adolescents and young adults accessing ART.
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Affiliation(s)
- Brian C Zanoni
- Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Moherndran Archary
- University of KwaZulu-Natal Nelson Mandela School of Medicine, Durban, South Africa
- Department of Pediatrics, King Edward Hospital, Durban, South Africa
| | - Sarah Buchan
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Ingrid T Katz
- Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jessica E Haberer
- Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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Katz IT, Bogart LM, Fu CM, Liu Y, Cox JE, Samuels RC, Chase T, Schubert P, Schuster MA. Barriers to HPV immunization among blacks and latinos: a qualitative analysis of caregivers, adolescents, and providers. BMC Public Health 2016; 16:874. [PMID: 27558506 PMCID: PMC4997748 DOI: 10.1186/s12889-016-3529-4] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Accepted: 08/16/2016] [Indexed: 01/05/2023] Open
Abstract
Background Despite recommendations that 11–12-year-olds receive the full three-shot Human papillomavirus (HPV) vaccine series, national HPV immunization coverage rates remain low. Disparities exist, with Blacks and Latinos being less likely than Whites to complete the series. We aimed to identify and compare barriers to HPV immunization perceived by healthcare providers, Black and Latino adolescents, and their caregivers to inform a clinic-based intervention to improve immunization rates. Methods We conducted semi-structured interviews between March and July 2014 with Black and Latino adolescents (n = 24), their caregivers (n = 24), and nurses (n = 18), and 2 focus groups with 18 physicians recruited from two pediatric primary care clinics. Qualitative protocol topics included: general perceptions and attitudes towards vaccines; HPV knowledge; and perceived individual and systems-level barriers affecting vaccine initiation and completion. Results Themes were identified and organized by individual and systems-level barriers to HPV immunization. Adolescents and their caregivers, particularly Blacks, expressed concerns about HPV being an untested, “newer” vaccine. All families felt they needed more information on HPV and found it difficult to return for multiple visits to complete the vaccine series. Providers focused on challenges related to administering multiple vaccines simultaneously, and perceptions of parental reluctance to discuss sexually transmitted infections. Conclusions Optimizing HPV immunization rates may benefit from a multi-pronged approach to holistically address provider, structural, and individual barriers to care. Further research should examine strategies for providing multiple modalities of support for providers, including a routinized system of vaccine promotion and delivery, and for addressing families’ concerns about vaccine safety and efficacy.
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Affiliation(s)
- Ingrid T Katz
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA. .,Massachusetts General Hospital, Center for Global Health, Boston, MassachusettsMA, USA. .,Harvard Medical School, Boston, Massachusetts, USA. .,Division of Women's Health, 1620 Tremont Street, 3rd Floor BWH, Boston, MA, 02120, USA.
| | - Laura M Bogart
- Harvard Medical School, Boston, Massachusetts, USA.,Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA.,RAND Corporation, Santa Monica, California, USA
| | - Chong Min Fu
- Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Yingna Liu
- Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Joanne E Cox
- Harvard Medical School, Boston, Massachusetts, USA.,Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Ronald C Samuels
- Harvard Medical School, Boston, Massachusetts, USA.,Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Tami Chase
- Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Pamela Schubert
- Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Mark A Schuster
- Harvard Medical School, Boston, Massachusetts, USA.,Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
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Earnshaw VA, Bogart LM, Klompas M, Katz IT. Medical mistrust in the context of Ebola: Implications for intended care-seeking and quarantine policy support in the United States. J Health Psychol 2016; 24:219-228. [PMID: 27257264 DOI: 10.1177/1359105316650507] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
This investigation explores Ebola conspiracy beliefs, a form of medical mistrust, and their potential impact on health behavior. Results of an online survey in the United States in December 2014 demonstrated that 16 percent of 202 participants held conspiracy beliefs. Participants who were less knowledgeable about Ebola, more mistrustful of medical organizations, and more xenophobic more strongly endorsed conspiracy beliefs. Participants who more strongly endorsed conspiracy beliefs reported that they would be less likely to seek care for Ebola and were less supportive of quarantining people returning from West Africa. Results suggest that medical mistrust may influence health behaviors during infectious disease outbreaks.
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Affiliation(s)
| | - Laura M Bogart
- 1 Harvard Medical School, USA.,2 Boston Children's Hospital, USA.,3 RAND Corporation, USA
| | - Michael Klompas
- 1 Harvard Medical School, USA.,4 Harvard Pilgrim Health Care Institute, USA.,5 Brigham and Women's Hospital, USA
| | - Ingrid T Katz
- 1 Harvard Medical School, USA.,5 Brigham and Women's Hospital, USA.,6 Massachusetts General Hospital, USA
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Magidson JF, Dietrich J, Otwombe KN, Sikkema KJ, Katz IT, Gray GE. Psychosocial correlates of alcohol and other substance use among low-income adolescents in peri-urban Johannesburg, South Africa: A focus on gender differences. J Health Psychol 2016. [PMID: 26936502 DOI: 10.1177/1359105316628739.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Alcohol and other drug use is prevalent among peri-urban, South African adolescents. We identified correlates of alcohol and other drug use by gender among adolescents (age = 16-18 years; N = 822) in peri-urban Johannesburg. Interviewer-administered surveys assessed sexual activity, alcohol and other drug use, and relevant psychosocial factors. In separate logistic regression models of alcohol and other drug use stratified by gender, violence exposure and sexual activity were associated with alcohol use for both males and females. For females only, depressive symptoms were associated with drug use. For males only, being older and sexually active were associated with drug use. Substance use interventions for South African adolescents should consider psychological health, sexual health, and tailoring by gender.
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Affiliation(s)
- Jessica F Magidson
- 1 Department of Psychiatry, Massachusetts General Hospital/Harvard Medical School, Boston, MA, USA
| | - Janan Dietrich
- 2 Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Kennedy N Otwombe
- 2 Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Kathleen J Sikkema
- 3 Department of Psychology and Neuroscience and Duke Global Health Institute, Duke University, Durham, NC, USA
| | - Ingrid T Katz
- 4 Division of Women's Health, Brigham and Women's Hospital/Harvard Medical School, Boston, MA, USA
| | - Glenda E Gray
- 2 Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Siedner MJ, Bassett IV, Katz IT, Ng CK, Bangsberg DR, Tsai AC. Reply to Okatch et al. Clin Infect Dis 2016; 62:670-1. [PMID: 26668342 PMCID: PMC4741363 DOI: 10.1093/cid/civ969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/25/2024] Open
Affiliation(s)
- Mark J Siedner
- Center for Global Health Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital Harvard Medical School
| | - Ingrid V Bassett
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital Harvard Medical School Department of Medicine, Medical Practice Evaluation Center, Massachusetts General Hospital
| | - Ingrid T Katz
- Center for Global Health Harvard Medical School Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | | | - David R Bangsberg
- Center for Global Health Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital Harvard Medical School Mbarara University of Science and Technology, Uganda
| | - Alexander C Tsai
- Center for Global Health Harvard Medical School Mbarara University of Science and Technology, Uganda Department of Psychiatry, Massachusetts General Hospital, Boston
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Magidson JF, Dietrich J, Otwombe KN, Sikkema KJ, Katz IT, Gray GE. Psychosocial correlates of alcohol and other substance use among low-income adolescents in peri-urban Johannesburg, South Africa: A focus on gender differences. J Health Psychol 2016; 22:1415-1425. [PMID: 26936502 DOI: 10.1177/1359105316628739] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Alcohol and other drug use is prevalent among peri-urban, South African adolescents. We identified correlates of alcohol and other drug use by gender among adolescents (age = 16-18 years; N = 822) in peri-urban Johannesburg. Interviewer-administered surveys assessed sexual activity, alcohol and other drug use, and relevant psychosocial factors. In separate logistic regression models of alcohol and other drug use stratified by gender, violence exposure and sexual activity were associated with alcohol use for both males and females. For females only, depressive symptoms were associated with drug use. For males only, being older and sexually active were associated with drug use. Substance use interventions for South African adolescents should consider psychological health, sexual health, and tailoring by gender.
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Affiliation(s)
- Jessica F Magidson
- 1 Department of Psychiatry, Massachusetts General Hospital/Harvard Medical School, Boston, MA, USA
| | - Janan Dietrich
- 2 Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Kennedy N Otwombe
- 2 Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Kathleen J Sikkema
- 3 Department of Psychology and Neuroscience and Duke Global Health Institute, Duke University, Durham, NC, USA
| | - Ingrid T Katz
- 4 Division of Women's Health, Brigham and Women's Hospital/Harvard Medical School, Boston, MA, USA
| | - Glenda E Gray
- 2 Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Katz IT, Bogart LM, Cloete C, Crankshaw TL, Giddy J, Govender T, Gaynes MR, Leone D, Losina E, Bassett IV. Understanding HIV-infected patients' experiences with PEPFAR-associated transitions at a Centre of Excellence in KwaZulu Natal, South Africa: a qualitative study. AIDS Care 2015; 27:1298-303. [PMID: 26300297 PMCID: PMC4548805 DOI: 10.1080/09540121.2015.1051502] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [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: 10/23/2022]
Abstract
South Africa was the largest recipient of funding from the President's Emergency Plan for AIDS Relief (PEPFAR) for antiretroviral therapy (ART) programs from 2004 to 2012. Funding decreases have led to transfers from hospital and non-governmental organization-based care to government-funded, community-based clinics. We conducted semi-structured interviews with 36 participants to assess patient experiences related to transfer of care from a PEPFAR-funded, hospital-based clinic in Durban to either primary care clinics or hospital-based clinics. Participant narratives revealed the importance of connectedness between patients and the PEPFAR-funded clinic program staff, who were described as respectful and conscientious. Participants reported that transfer clinics were largely focused on dispensing medication and on throughput, rather than holistic care. Although participants appreciated the free treatment at transfer sites, they expressed frustration with long waiting times and low perceived quality of patient-provider communication, and felt that they were treated disrespectfully. These factors eroded confidence in the quality of the care. The transfer was described by participants as hurried with an apparent lack of preparation at transfer clinics for new patient influx. Formal (e.g., counseling) and informal (e.g., family) social supports, both within and beyond the PEPFAR-funded clinic, provided a buffer to challenges faced during and after the transition in care. These data support the importance of social support, adequate preparation for transfer, and improving the quality of care in receiving clinics, in order to optimize retention in care and long-term adherence to treatment.
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Affiliation(s)
- Ingrid T Katz
- Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
- Massachusetts General Hospital Center for Global Health, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, United States of America
| | - Laura M Bogart
- Harvard Medical School, Boston, Massachusetts, United States of America
- Boston Children’s Hospital, Boston, Massachusetts, United States of America
- Harvard University Center for AIDS Research (CFAR), Boston, Massachusetts, United States of America
| | | | - Tamaryn L Crankshaw
- Health Economics and HIV and AIDS Research Division (HEARD), University of KwaZulu-Natal, KwaZulu-Natal, South Africa
| | | | | | - Melanie R Gaynes
- Division of General Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Dominick Leone
- Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
- Department of Biostatistics and Epidemiology, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Elena Losina
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Department of Biostatistics and Epidemiology, Boston University School of Public Health, Boston, Massachusetts, United States of America
- Harvard University Center for AIDS Research (CFAR), Boston, Massachusetts, United States of America
- Division of Rheumatology, Department of Medicine, and Department of Orthopedic Surgery, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
| | - Ingrid V Bassett
- Division of General Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Harvard University Center for AIDS Research (CFAR), Boston, Massachusetts, United States of America
- Division of Infectious Disease, Massachusetts General Hospital, Boston, Massachusetts, United States of America
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Affiliation(s)
- Ingrid T Katz
- Division of Women's Health, Brigham and Women's Hospital, Boston, MA 02115, USA; Harvard Medical School, Boston, MA, USA; Massachusetts General Hospital Center for Global Health, Boston, MA, USA.
| | - Mark J Siedner
- Harvard Medical School, Boston, MA, USA; Massachusetts General Hospital Center for Global Health, Boston, MA, USA
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Affiliation(s)
- Ingrid T. Katz
- From Brigham and Women's Hospital, Massachusetts General Hospital Center for Global Health, and Harvard Medical School, Boston, and Harvard School of Public Health, Boston, Massachusetts
| | - David E. Shapiro
- From Brigham and Women's Hospital, Massachusetts General Hospital Center for Global Health, and Harvard Medical School, Boston, and Harvard School of Public Health, Boston, Massachusetts
| | - Ruth Tuomala
- From Brigham and Women's Hospital, Massachusetts General Hospital Center for Global Health, and Harvard Medical School, Boston, and Harvard School of Public Health, Boston, Massachusetts
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