An evaluation of the impact of social and structural determinants of health on forgone care during the COVID-19 pandemic in Baltimore, Maryland

Evidence suggests that reductions in healthcare utilization, including forgone care, during the COVID-19 pandemic may be contributing towards excess morbidity and mortality. The objective of this study was to describe individual and community-level correlates of forgone care during the COVID-19 pandemic. We conducted a cross-sectional, secondary data analysis of participants (n = 2,003) who reported needing healthcare in two population-representative surveys conducted in Baltimore, MD in 2021 and 2021-2022. Abstracted data included the experience of forgone care, socio-demographic data, comorbidities, financial strain, and community of residence. Participant's community of residence were linked with data acquired from the Baltimore Neighborhood Indicators Alliance relevant to healthcare access and utilization, including walkability and internet access, among others. The data were analyzed using weighted random effects logistic regression. Individual-level factors found to be associated with increased odds for forgone care included individuals age 35-49 (compared to 18-34), female sex, experiencing housing insecurity during the pandemic, and the presence of functional limitations and mental illness. Black/African American individuals were found to have reduced odds of forgone care, compared to any other race. No community-level factors were significant in the multilevel analyses. Moving forward, it will be critical that health systems identify ways to address any barriers to care that populations might be experiencing, such as the use of mobile health services or telemedicine platforms. Additionally, public health emergency preparedness planning efforts must account for the unique needs of communities during future crises, to ensure that their health needs can continue to be met. Finally, additional research is needed to better understand how healthcare access and utilization practices have changed during versus before the pandemic.

Relationship between HIV viral suppression and multidrug resistant tuberculosis treatment outcomes

The impact of HIV viral suppression on multidrug resistant tuberculosis (MDR-TB) treatment outcomes among people with HIV (PWH) has not been clearly established. Using secondary data from a cluster-randomized clinical trial among people with MDR-TB in South Africa, we examined the effects of HIV viral suppression at MDR-TB treatment initiation and throughout treatment on MDR-TB outcomes among PWH using multinomial regression. This analysis included 1479 PWH. Viral suppression (457, 30.9%), detectable viral load (524, 35.4%), or unknown viral load (498, 33.7%) at MDR-TB treatment initiation were almost evenly distributed. Having a detectable HIV viral load at MDR-TB treatment initiation significantly increased risk of death compared to those virally suppressed (relative risk ratio [RRR] 2.12, 95% CI 1.11-4.07). Among 673 (45.5%) PWH with a known viral load at MDR-TB outcome, 194 (28.8%) maintained suppression, 267 (39.7%) became suppressed, 94 (14.0%) became detectable, and 118 (17.5%) were never suppressed. Those who became detectable (RRR 11.50, 95% CI 1.98-66.65) or were never suppressed (RRR 9.28, 95% CI 1.53-56.61) were at significantly increased risk of death (RRR 6.37, 95% CI 1.58-25.70), treatment failure (RRR 4.54, 95% CI 1.35-15.24), and loss to follow-up (RRR 7.00, 95% CI 2.83-17.31; RRR 2.97, 95% CI 1.02-8.61) compared to those who maintained viral suppression. Lack of viral suppression at MDR-TB treatment initiation and failure to achieve or maintain viral suppression during MDR-TB treatment drives differences in MDR-TB outcomes. Early intervention to support access and adherence to antiretroviral therapy among PWH should be prioritized to improve MDR-TB treatment outcomes.

Travel distance to rifampicin-resistant tuberculosis treatment and its impact on loss to follow-up: the importance of continued RR-TB treatment decentralization in South Africa

BACKGROUND

Understanding why patients experience loss to follow-up (LTFU) is essential for TB control. This analysis examines the impact of travel distance to RR-TB treatment on LTFU, which has yet to be analyzed within South Africa.

METHODS

We retrospectively analyzed 1436 patients treated for RR-TB at ten South African public hospitals. We linked patients to their residential ward using data reported to NHLS and maps available from the Municipal Demarcation Board. Travel distance was calculated from each patient's ward centroid to their RR-TB treatment site using the georoute command in Stata. The relationship between LTFU and travel distance was modeled using multivariable logistic regression.

RESULTS

Among 1436 participants, 75.6% successfully completed treatment and 24.4% were LTFU. The median travel distance was 40.96 km (IQR: 17.12, 63.49). A travel distance > 60 km increased odds of LTFU by 91% (p = 0.001) when adjusting for HIV status, age, sex, education level, employment status, residential locale, treatment regimen, and treatment site.

CONCLUSION

People living in KwaZulu-Natal and Eastern Cape travel long distances to receive RR-TB care, placing them at increased risk for LTFU. Policies that bring RR-TB treatment closer to patients, such as further decentralization to PHCs, are necessary to improve RR-TB outcomes.

Prevalence of SARS-CoV-2 Infection among Children and Adults in 15 US Communities, 2021

During January-August 2021, the Community Prevalence of SARS-CoV-2 Study used time/location sampling to recruit a cross-sectional, population-based cohort to estimate SARS-CoV-2 seroprevalence and nasal swab sample PCR positivity across 15 US communities. Survey-weighted estimates of SARS-CoV-2 infection and vaccine willingness among participants at each site were compared within demographic groups by using linear regression models with inverse variance weighting. Among 22,284 persons >2 months of age and older, median prevalence of infection (prior, active, or both) was 12.9% across sites and similar across age groups. Within each site, average prevalence of infection was 3 percentage points higher for Black than White persons and average vaccine willingness was 10 percentage points lower for Black than White persons and 7 percentage points lower for Black persons than for persons in other racial groups. The higher prevalence of SARS-CoV-2 infection among groups with lower vaccine willingness highlights the disparate effect of COVID-19 and its complications.

A Systematic Review and Psychometric Appraisal of Instruments Measuring Tuberculosis Stigma in Sub-Saharan Africa

Tuberculosis (TB) stigma is one barrier to TB testing, treatment uptake and treatment completion. Therefore, stigma measurement must be approached through rigorous scientific methodology in order to accurately and reliably estimate the impact of TB stigma on treatment outcomes. The aim of this systematic review is to evaluate the methods and instruments used to measure TB stigma and interrogate strategies used to culturally validate measures of TB stigma in global research. Two reviewers used the PRISMA method to extract and analyze the existing body of literature on TB stigma in Sub-Saharan Africa. A thorough search was performed using three data bases generating 2,302 independent studies. After systematic screening, this review includes 28 studies. Of those studies, 13 used a psychometrically validated instrument while 15 used informal questionnaires or proxy variables to measure stigma. Psychometric appraisal was limited due to the number of studies that measured stigma using unvalidated questionnaires or proxy variables. The Patient and Community Perceptions of TB scales validated by Van Rie et al. were the most commonly used instruments to measure TB stigma; additionally, many instruments were not culturally or linguistically validated in Sub-Saharan Africa. Our appraisal emphasizes the need for reliable and valid instruments to measure TB stigma in low- and middle-income countries most affected by TB.

Exploring HIV disease indicators at MDR-TB treatment initiation in South Africa

BACKGROUND: Understanding relationships between HIV and multidrug-resistant TB (MDR-TB) is crucial for ensuring successful MDR-TB outcomes.METHODS: We used a cross-sectional analysis to evaluate sociodemographic and clinical characteristics as correlates of antiretroviral therapy (ART) use, having an HIV viral load (VL) result, and HIV viral suppression in a cross-sectional sample of people with HIV (PWH) and MDR-TB enrolled in a cluster-randomized trial of nurse case management to improve MDR-TB outcomes.RESULTS: Among 1,479 PWH, the mean age was 37.1 years; 809 (54.7%) were male, and 881 (59.6%) were taking ART. Housing location, employment status, and CD4 count differed significantly between those taking vs. those not taking ART. Among the 881 taking ART, 681 (77.3%) had available HIV VL results. Housing location, CD4 count, and prior history of TB differed significantly between those with and without a VL result. Among the 681 with a VL result, 418 (61.4%) were virally suppressed. Age, education level, CD4 count, TB history, housing location, and ART type differed significantly between those with and without viral suppression.CONCLUSION: PWH presenting for MDR-TB treatment with a history of TB, taking a protease inhibitor, or living in a township may risk poor MDR-TB outcomes.

Successful Multidrug-Resistant Tuberculosis Treatment Without HIV Viral Suppression: A Missed Opportunity

BACKGROUND

Coinfection with multidrug-resistant tuberculosis (MDR-TB) and HIV is common, but few published studies examine how undergoing MDR-TB treatment affects HIV disease indicators.

METHODS

Using data from a nested, retrospective cohort of people with HIV (PWH) and successful MDR-TB treatment outcomes, we built multivariable regression models to explore correlates of HIV viral suppression at MDR-TB treatment completion.

RESULTS

Among 531 PWH successfully treated for MDR-TB, mean age was 37.4 years (SD 10.2, interquartile range 30-43), 270 (50.8%) were male, 395 (74.4%) were virally suppressed at MDR-TB outcome, and 259 (48.8%) took bedaquiline. Older age (adjusted odds ratio [aOR] 1.04, 95% confidence interval [CI]: 1.01 to 1.06) increased odds of viral suppression, while having a prior TB episode (aOR 0.45, 95% CI: 0.31 to 0.64), having a detectable viral load at MDR-TB treatment initiation (aOR 0.17, 95% CI: 0.09 to 0.30), living in a township (aOR 0.49, 95% CI: 0.28 to 0.87), and being changed from efavirenz-based antiretroviral therapy (ART) to a protease inhibitor due to bedaquiline usage (aOR 0.19, 95% CI: 0.04 to 0.82) or not having an ART change while on bedaquiline (aOR 0.29, 95% CI: 0.11 to 0.75) lowered odds of viral suppression. Changing from efavirenz to nevirapine due to bedaquiline usage did not significantly affect odds of viral suppression (aOR 0.41, 95% CI: 0.16 to 1.04).

CONCLUSIONS

Increased pill burden and adverse treatment effects did not significantly affect HIV viral suppression while switching ART to a protease inhibitor to accommodate bedaquiline or not changing ART while taking bedaquiline did, suggesting that PWH and MDR-TB may benefit from additional support if they must switch ART.

High Primary COVID-19 Vaccine Series Completion by People Who Inject Drugs When Colocating Services at a Syringe Services Van

OBJECTIVE

The aim of the study is to describe the impact of colocating COVID-19 vaccinations with local syringe service programs on vaccine completion among people who inject drugs.

METHODS

Data were derived from 6 community-based clinics. People who inject drugs who received at least one COVID-19 vaccine from a colocated clinic partnering with a local syringe service program were included in the study. Vaccine completion was abstracted from electronic medical records; additional vaccinations were abstracted using health information exchanges embedded within the electronic medical records.

RESULTS

Overall, 142 individuals with a mean age of 51 years, predominantly male (72%) and Black, non-Hispanic (79%) received COVID-19 vaccines. More than half elected to receive a 2-dose mRNA vaccine (51.4%). Eighty-five percent completed a primary series, and 71% of those who received a mRNA vaccine completed the 2-dose series. Booster uptake was 34% in those completing a primary series.

CONCLUSIONS

Colocated clinics are an effective means of reaching vulnerable populations. As the COVID-19 pandemic continues and need for annual booster vaccines arises, it is important to bolster public support and funding to continue low-barrier preventive clinics colocated with harm reduction services for this population.

A distributional regression approach to modeling the impact of structural and intermediary social determinants on communities burdened by tuberculosis in Eastern Amazonia - Brazil

BACKGROUND

Tuberculosis (TB) is a disease that is influenced by social determinants of health. However, the specific structural and intermediary determinants of TB in Eastern Amazonia remain unclear. Despite being rich in natural resources, the region faces significant challenges related to poverty, inequality, and neglected diseases. The objective of this study was to use mathematical modeling to evaluate the influence of structural and intermediary determinants of health on TB in Eastern Amazonia, Brazil.

METHODS

This cross-sectional included all TB cases diagnosed and registered in the Notifiable Diseases Information System (SINAN) from 2001 to 2017. Data on social determinants were collected at the census tract level. The generalized additive model for location, scale, and shape (GAMLSS) framework was employed to identify the effect of social determinants on communities with a high TB prevalence. The Double Poisson distribution (DPO) was chosen, and inclusion of quadratic effects was tested.

RESULTS

A total of 1730 individuals were diagnosed with TB and reported in SINAN during the analyzed period. The majority were female (59.3%), aged 31 to 59 years (47.6%), identified as blacks (67.9%), and had incomplete elementary education (46.6%). The prevalence of alcoholism was 8.6% and mental illness was 0.7%. GAMLSS analyses demonstrated that the risk of community incidence of TB is associated with the proportion of the population lacking basic sanitation, as well as with the age groups of 16-31 years and > 61 years.

CONCLUSIONS

The study highlights the strategic utility of GAMLSS in identifying high-risk areas for TB. Models should encompass a broader range of social determinants to inform policies aimed at reducing inequality and achieving the goals of the End TB strategy.

Multilevel Stigma and Its Associations with Medical Care Ratings Among Men Who Have Sex With Men in HPTN 078

INTRODUCTION

Our research assessed associations between stigma-related variables and medical care ratings among clients with HIV in HIV Prevention Trials Network (HPTN) 078 who were men who have sex with men (MSM).

METHODS

Logistic regression explored care ratings, stigma, socio-demographics (N = 637). Qualitative thematic coding and themes explored stigmatizing experiences in different settings (N = 111).

RESULTS

Whites were twice as likely as African-Americans to report high care ratings (P < .05). Clients who reported familial exclusion due to having sex with men were 40% less likely to report high medical care ratings (P < .05). Clients who agreed healthcare providers think people with HIV "sleep around" were half as likely to report high care ratings (P < .08). Stigmatization included "treating me like they'll catch HIV from my hand," and care avoidance so others didn't "know I was having sex with men".

CONCLUSIONS

Providers can promote African American MSM client retention with more affirming healthcare provision, namely minimizing assumptions and addressing identities and client needs beyond just HIV care.

Impact of the COVID-19 Pandemic on HIV Healthcare Service Engagement, Treatment Adherence, and Viral Suppression in the United States: A Systematic Literature Review

The COVID-19 pandemic has necessitated adaptations in how healthcare services are rendered. However, it is unclear how these adaptations have impacted HIV healthcare services across the United States. We conducted a systematic review to assess the impacts of the pandemic on service engagement, treatment adherence, and viral suppression. We identified 26 total studies spanning the beginning of the pandemic (March 11, 2020) up until November 5, 2021. Studies were conducted at the national, state, and city levels and included representation from all four CDC HIV surveillance regions. Studies revealed varying impacts of the pandemic on HIV healthcare retention/engagement, medication adherence, and viral suppression rates, including decreases in HIV healthcare visits, provider cancellations, and inability to get prescription refills. Telehealth was critical to ensuring continued access to care and contributed to improved retention and engagement in some studies. Disparities existed in who had access to the resources needed for telehealth, as well as among populations living with HIV whose care was impacted by the pandemic.

"Living like an empty gas tank with a leak": Mixed methods study on post-acute sequelae of COVID-19

BACKGROUND

The burden and presentation of post-acute sequela of SARS-CoV-2 infection (PASC) are a developing major public health concern.

OBJECTIVES

To characterize the burden of PASC in community-dwelling individuals and understand the experiences of people living with PASC.

METHODS

This mixed-methods study of COVID-19 positive community-dwelling persons involved surveys and in-depth interviews. Main outcome was self-report of possible PASC symptoms 3 weeks or longer after positive COVID-19 test. In-depth interviews were guided by a semi-structured interview guide with open-ended questions and probes based on emerging literature on PASC and the impact of COVID-19.

RESULTS

With a survey response rate of 70%, 442 participants were included in this analysis, mean (SD) age 45.4 (16.2) years, 71% female, 12% Black/African American. Compared to those with no PASC symptoms, persons who reported PASC symptoms were more likely to be older (mean age: 46.5 vs. 42; p = 0.013), female (74.3% vs. 61.2%; p = 0.010), to have pre-existing conditions (49.6% vs. 34%; p = 0.005), and to have been hospitalized for COVID-19 (14.2% vs. 2.9%; p = 0.002). About 30% of the participants experienced severe fatigue; the proportion of persons reporting severe fatigue was 7-fold greater in those with PASC symptoms (Adjusted Prevalence Ratio [aPR] 6.73, 95%CI: 2.80-16.18). Persons with PASC symptoms were more likely to report poor quality of life (16% vs. 5%, p<0.001) and worse mental health functioning (Mean difference: -1.87 95%CI: -2.38, -1.37, p<0.001). Themes from in-depth interviews revealed PASC was experienced as debilitating.

CONCLUSIONS

In this study, the prevalence of PASC among community-dwelling adults was substantial. Participants reported considerable coping difficulties, restrictions in everyday activities, invisibility of symptoms and experiences, and impediments to getting and receiving PASC care.

Sexual behavior and medication adherence in men who have sex with men participating in a pre-exposure prophylaxis study of combinations of Maraviroc, Tenofovir Disoproxil Fumarate and/or Emtricitabine (HPTN 069/ACTG 5305)

HPTN 069/ACTG 5305 was designed to evaluate potential new PrEP regimens that included maraviroc, tenofovir disoproxil fumarate, and/or emtricitabine. The current analyses assessed antiretroviral (ARV) plasma concentrations in relation to sexual behavior in 224 cisgender men who have sex with men and 2 transgender women at risk for HIV. Poisson generalized estimating equations (GEE) regression were used to test for associations between self-reported sexual behavior, sociodemographic, behavioral variables, and study drug levels The median (IQR) age was 30 [25, 37] years old; 48.2% had completed college; 27.4% were Black and 21.7% Latino. At weeks 24 and 48, one third of participants reported condomless anal sex (CAS) in the prior month with more than one partner. CAS was associated with daily ARV drug use (χ2 = 12.64, p = 0.002). Older individuals and those with greater education were more likely to ingest ARV drugs daily (χ2 = 9.36, p = 0.009 and χ2 = 8.63, p = 0.013, respectively), while neither race nor ethnicity was associated with daily ARV drug use. Participants who reported recent condomless anal sex and/or advanced education had higher rates of daily ARV drug use. These data support the need for ongoing adherence counseling in clinical trials of new PrEP modalities.

Multimorbidity classes indicate differential patterns of health care engagement among people who inject drugs

BACKGROUND

Aging people who inject drugs (PWID) have complex health needs. Health care management could be complicated by persistent substance use, multiple health challenges, and inconsistent access to care. However, we know little about the relationship between chronic multimorbidity and health care engagement in this population. The purpose of this study is to characterize patterns and correlates of chronic disease multimorbidity among PWID.

METHODS

We conducted a latent class analysis (LCA) using data from the AIDS Linked to the IntraVenous Experience (ALIVE) Study, a community-based observational cohort, to determine classes of multimorbid chronic diseases. We then conducted regressions to determine factors associated with class membership and the impact of each multimorbid class on health events and utilization.

RESULTS

Of 1387 individuals included, the majority were male (67%) and Black (81%), with a mean age of 53 years. We identified four classes of multimorbidity: Low Multimorbidity (54%), and Low Multimorbidity Including Psychiatric Comorbidity (26%), Multimorbidity (12%), and Multimorbidity Including Psychiatric Comorbidity (7%). Female sex, baseline age, and receipt of disability were factors significantly associated with membership in all three classes compared to the Low Multimorbidity class. Additionally, PWID in these three classes were significantly more likely to utilize emergency room and outpatient health care. Membership in both classes with psychiatric comorbidity was associated with significantly higher adjusted odds of receiving medication for opioid use disorder.

DISCUSSION

Holistic health care systems can best address the needs of aging PWID with integrated care that provides harm reduction, substance use and mental health treatment together, and wrap around services.

Cardiac postacute sequelae symptoms of SARS-CoV-2 in community-dwelling adults: cross-sectional study

Objective

To examine risk factors for cardiac-related postacute sequelae of SARS-CoV-2 infection (PASC) in community-dwelling adults after acute COVID-19 infection.

Methods

We performed a cross-sectional analysis among adults who tested positive for COVID-19. Outcomes were self-reported cardiac-related PASC. We conducted stepwise multivariable logistic regression to assess association between the risk factors (existing cardiovascular disease (CVD), pre-existing conditions, days since positive test, COVID-19 hospitalisation, age, sex, education, income) and cardiac-related PASC.

Results

In a sample of 442 persons, mean (SD) age was 45.4 (16.2) years, 71% were women, 13% were black, 46% had pre-existing conditions, 23% had cardiovascular (CV) risk factors and 4% had CVD. Prevalence of cardiac PASC was 43% and newly diagnosed cardiac conditions were 27%. The odds for cardiac-related PASC were higher among persons with underlying pre-existing conditions (adjusted OR (aOR): 2.00, 95% CI: 1.28 to 3.10) and among those who were hospitalised (aOR: 3.03, 95% CI: 1.58 to 5.83).

Conclusions

More than a third of persons with COVID-19 reported cardiac-related PASC symptoms. Underlying CVD, pre-existing diseases, age and COVID-19 hospitalisation are possible risk factors for cardiac-related PASC symptoms. COVID-19 may exacerbate CV risk factors and increase risk of complications.

Refining a Multicomponent Intervention to Increase Perceived HIV Risk and PrEP Initiation: Focus Group Study Among Black Sexual Minority Men

Background

Increased preexposure prophylaxis (PrEP) initiation is needed to substantially decrease HIV incidence among Black sexual minority men (BSMM). However, BSMM perceive others as PrEP candidates instead of themselves and are less likely than other groups to use PrEP if prescribed. Peers and smartphone apps are popular HIV prevention intervention tools typically used independently. However, they could be useful together in a multicomponent strategy to improve perceived HIV risk and PrEP initiation for this group. Information regarding attitudes and preferences toward this multicomponent strategy is limited.

Objective

The goal of this study is to obtain attitudes and perspectives regarding the design of a multicomponent intervention that uses a smartphone app and a peer change agent (PCA) to increase perceived HIV risk and PrEP initiation. The intervention will be refined based on thematic findings for a culturally responsive approach.

Methods

Data were obtained guided by life course theory and the health belief model using 12 focus groups and 1 in-depth interview among HIV-negative BSMM from Baltimore, MD, between October 2019 and May 2020 (n=39). Groups were stratified by the following ages: 18 to 24 years, 25 to 34 years, and 35 years and older. Participants were provided details regarding an existing mobile app diary to self-monitor sexual behaviors and a hypothetical PCA with whom to review the app. Facilitators posed questions regarding perceived HIV risk, attitudes toward the app, working with a PCA, and preferences for PCA characteristics and approaches.

Results

Most participants identified as homosexual, gay, or same gender-loving (26/38, 68%), were employed (26/38, 69%), single (25/38, 66%), and interested in self-monitoring sexual behaviors (28/38, 68%). However, themes suggested that participants had low perceived HIV risk, that self-monitoring sexual behaviors using a mobile app diary was feasible but could trigger internalized stigma, and that an acceptable PCA should be a possible self for BSMM to aspire to but they still wanted clinicians to “do their job.”

Conclusions

HIV-negative BSMM have dissonant attitudes regarding perceived HIV risk and the utility of a mobile app and PCA to increase perceived HIV risk and PrEP initiation. Future research will explore the feasibility, acceptability, and preliminary impact of implementing the multicomponent intervention on perceived HIV risk and PrEP initiation among BSMM in a pilot study.

COVID-19 Vaccination and Communicable Disease Testing Services' Integration Within a Syringe Services Program: A Program Brief

ABSTRACT

People who inject drugs often have a higher prevalence of risk factors associated with coronavirus disease 2019 (COVID-19) infection and associated morbidity and mortality, compounded by challenges in health care access. This increased vulnerability underscores the critical need to prioritize people who inject drug in ongoing COVID-19 vaccination efforts. Co-location of syringe services, COVID-19 vaccination services, and other communicable disease testing has proved an effective model to provide necessary interventions without creating additional barriers. Here, we describe a partnership between the Baltimore City Health Department, Johns Hopkins Mobile Vaccine Unit, and the Center for Infectious Disease and Nursing Innovation at the Johns Hopkins School of Nursing to provide COVID-19 vaccination, HIV and sexually transmitted infection testing, wound care, and linkage to care services co-located with a long-running syringe services program. We describe the services offered by each partner and lessons learned from this community-based co-location of services initiative.

Examining family planning and adverse pregnancy outcomes for women with active tuberculosis disease: a systematic review

OBJECTIVES

(1) Summarise and evaluate the current evidence of tuberculosis (TB)-associated pregnancy outcomes, (2) evaluate the state of the science of family planning during TB treatment and (3) provide recommendations to move forward to improve care and outcomes during TB disease.

DESIGN

Systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines.

DATA SOURCES

PubMed, Embase, CINAHL, Cochrane, Web of Science and Scopus were searched from September 2009 to November 2021.

ELIGIBILITY CRITERIA

Studies were included if they assessed pregnant women with active TB, drug-resistant TB (DR-TB) or TB/HIV coinfection and examined pregnancy, maternal, fetal/birth and TB or TB/HIV coinfection outcomes. Studies were also included if they examined family planning services among women initiating TB treatment.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers extracted data using PRISMA guidelines and conducted quality assessment using the Joanna-Briggs Institute Critical Appraisal Tools. The level of evidence was reported using the Johns Hopkins Evidence-Based Practice guidelines.

RESULTS

69 studies were included in this review. Case reports, case series, case controls, cohort studies, secondary data analyses and a service delivery improvement project conducted in 26 countries made up the totality of the evidence. Most studies reported pregnancy complications for mothers (anaemia, postpartum haemorrhage, deaths) and fetuses or newborns (low birth weight, premature birth, and spontaneous or induced abortions). Few studies discussed the value of offering family planning to prevent adverse pregnancy outcomes. One study examined the effect of a provider training on contraceptive use with reported increased contraceptive use.

CONCLUSIONS

Integrating family planning services within a TB treatment programme is essential to reduce adverse TB-associated maternal-child outcomes. Despite well-established adverse pregnancy outcomes, little attention has been paid to family planning to prevent poor pregnancy outcomes for women with TB/DR-TB. Recommendations for clinicians, TB programmes and researchers are provided and reflect evidence presented in this review.

Clinical outcomes after IL-6 blockade in patients with COVID-19 and HIV: a case series

BACKGROUND

In hospitalized people with HIV (PWH) there is an increased risk of mortality from COVID-19 among hospitalized PWH as compared to HIV-negative individuals. Evidence suggests that tocilizumab-a humanized monoclonal interleukin (IL)-6 receptor inhibitor (IL-6ri) antibody-has a modest mortality benefit when combined with corticosteroids in select hospitalized COVID-19 patients who are severely ill. Data on clinical outcomes after tocilizumab use in PWH with severe COVID-19 are lacking.

CASE PRESENTATION

We present a multinational case series of 18 PWH with COVID-19 who were treated with IL-6ri's during the period from April to June 2020. Four patients received tocilizumab, six sarilumab, and eight received an undocumented IL-6ri. Of the 18 patients in the series, 4 (22%) had CD4 counts < 200 cells/mm³; 14 (82%) had a suppressed HIV viral load. Eight patients (44%), all admitted to ICU, were treated for secondary infection; 5 had a confirmed organism. Of the four patients with CD4 counts < 200 cells/mm³, three were treated for secondary infection, with 2 confirmed organisms. Overall outcomes were poor-12 patients (67%) were admitted to the ICU, 11 (61%) required mechanical ventilation, and 7 (39%) died.

CONCLUSIONS

In this case series of hospitalized PWH with COVID-19 and given IL-6ri prior to the common use of corticosteroids, there are reports of secondary or co-infection in severely ill patients. Comprehensive studies in PWH, particularly with CD4 counts < 200 cells, are warranted to assess infectious and other outcomes after IL-6ri use, particularly in the context of co-administered corticosteroids.

Reframing Intersectional Stigma for a South African Context Integrating Tuberculosis, HIV and Poverty Stigmas

ABSTRACT

Intersectionality is closely intertwined with Black feminism within the context of the United States. As a result, intersectionality is often overlooked in non-Western contexts where racial homogeneity may reduce some of the impact of race on marginalization. This article will look at intersectional stigma from the South African context using the tuberculosis/HIV (TB/HIV) treatment environment in South Africa to exemplify intersectionality's versatility as an analytic method outside of the United States. We will use colonial history and contemporary research to reframe intersectionality considering a new set of stigmatized identities, including HIV stigma, TB stigma, and poverty stigma, to create a situation-specific framework adapted from a model by Bulent Turan and colleagues.

Evaluating Integrated Care for People Living With HIV and Multidrug-Resistant Tuberculosis in South Africa: A Case-Based Approach Using the Chronic Care Model

ABSTRACT

In South Africa, tuberculosis (TB) and multidrug-resistant TB (MDR-TB) frequently occur in people living with HIV. World Health Organization guidelines recommend the integration of MDR-TB and HIV care but, in practice, fully integrated care is difficult to achieve. In this article, we use five elements of the Chronic Care Model as a framework for evaluating a case of integrated MDR-TB/HIV care and to highlight opportunities for nurses to improve care delivery and patient outcomes. We apply the Chronic Care Model framework to a concrete example by examining the case of a 33-year-old man who developed MDR-TB treatment failure while concurrently taking a powerful new MDR-TB antiretroviral therapy regimen for his HIV.

HIV care and treatment models and their association with medication possession ratio among treatment-experienced adults in three African countries

OBJECTIVE

How clinics structure the delivery of antiretroviral therapy (ART) services may influence patient adherence. We assessed the relationship between models of HIV care delivery and adherence as measured by medication possession ratio (MPR) among treatment-experienced adults in Tanzania, Uganda and Zambia.

METHODS

Eighteen clinics were grouped into three models of HIV care. Model 1-Traditional and Model 2-Mixed represented task-sharing of clinical services between physicians and clinical officers, distinguished by whether nurses played a role in clinical care; in Model 3-Task-Shifted, clinical officers and nurses shared clinical responsibilities without physicians. We assessed MPR among 3,419 patients and calculated clinic-level MPR summaries. We then calculated the mean differences of percentages and adjusted residual ratio (aRR) of the association between models of care and incomplete adherence, defined as a MPR <90%, adjusting for individual-level characteristics.

RESULTS

In the adjusted analysis, patients in Model 1-Traditional were more likely than patients in Model 2-Mixed to have MPR <90% (aRR = 1.60, 95% CI 1-2.48). Patients in Model 1-Traditional were no more likely than patients in Model 3-Task-Shifted to have a MPR <90% (aRR = 1.58, 95% 0.88-2.85). There was no evidence of differences in MPR <90% between Model 2-Mixed and Model 3-Task-Shifted (aRR = 0.99, 95% CI 0.59-1.66).

CONCLUSION

Non-physician-led ART programmes were associated with adherence levels as good as or better than physician-led ART programmes. Additional research is needed to optimise models of care to support patients on lifelong treatment.

Risk factors for poor engagement in drug-resistant TB care in South Africa: a systematic review

BACKGROUND

Metrics of poor patient engagement, including missed appointments, treatment interruption, sub-optimal medication adherence, and loss to follow-up, have been linked to poor clinical multidrug-resistant TB (MDR-TB) outcomes. Understanding the risk factors for poor patient engagement is necessary to improve outcomes and control TB. This review synthesizes the risk factors for poor patient engagement in MDR-TB treatment across South Africa.

DESIGN

A systematic review of five databases (PubMed, Embase, CINAHL, Cochrane, and Web of Science) was conducted, covering articles published between 2010 and 2020. Articles were included if they provided information about risk factors associated with poor engagement among adults (⩾15 years) in treatment for MDR-TB in South Africa. Reviews, editorials, abstracts, and case studies were excluded.

RESULTS

Six studies met the inclusion criteria. Male sex and younger age were the most consistently identified risk factors for poor engagement; however, there was a lack of consistency in the choice of covariates, measurement of the variables, analytic methods, and significant factors associated with poor engagement between studies. Alcohol use, substance use, living with HIV, pulmonary TB site, and ethnicity were all identified as risk factors in at least one included study, while formal housing and steady employment were found to be protective.

CONCLUSION

The available literature offers little cohesive data to address poor patient engagement in this population. Further research needs to focus on identifying and addressing risk factors for poor patient engagement. This is particularly salient within the context of newer all-oral and short-course MDR-TB treatment regimens.

Determining the prevalence of tuberculosis in emergency departments in the Eastern Cape region of South Africa and the utility of the World Health Organization tuberculosis screening tool

BACKGROUND

South Africa (SA) faces a significant tuberculosis (TB) burden complicated by high rates of HIV-TB co-infection. In SA, emergency departments (EDs) play an important role in screening for TB.

OBJECTIVES

To determine the prevalence of TB in the ED and the effectiveness of the World Health Organization (WHO) TB screening tool.

METHODS

This was a cross-sectional observational study, conducted in the ED at Livingstone Hospital, Port Elizabeth, from 4 June to 15 July 2018. All patients aged &gt;18 years and able to consent were administered the WHO TB screening questions and underwent a point-of-care HIV test and demographic data collection. Patients were followed up for 1 year and tracked in the National Health Laboratory Service database to determine TB status using laboratory testing.

RESULTS

Over the study period, 790 patients were enrolled. Overall, 121 patients (15.3%) were TB-positive, with 46 (38.0%) diagnosed after presenting to the ED and 75 (62.0%) with a previous TB history determined by self-report or confirmed laboratory testing. A greater proportion of the TB-positive patients were HIV-positive (49.6%) compared with the TB-negative population (24.8%). TB-positive individuals were more likely to present to the ED with a chief complaint of shortness of breath (SoB) (18.2%) compared with the TB-negative population (10.5%). Overall, the WHO TB screening tool had poor sensitivity (46.5%) and specificity (62.5%) for identifying TB-positive patients in the ED. A multiple logistic regression analysis, controlled for age and sex, showed HIV status (odds ratio (OR) 2.81; p&lt;0.001) and SoB (OR 2.19; p&lt;0.05) to be significant predictors of TB positivity. Adding positive HIV status and a presenting complaint of SoB increased sensitivity to 78.3%.

CONCLUSIONS

EDs in SA face a high burden of TB. While WHO screening guidelines identify some of these patients, including routine HIV testing in the ED could significantly affect the number of TB diagnoses made.

Performance of a high-throughput next-generation sequencing method for analysis of HIV drug resistance and viral load

OBJECTIVES

To evaluate the performance of a high-throughput research assay for HIV drug resistance testing based on whole genome next-generation sequencing (NGS) that also quantifies HIV viral load.

METHODS

Plasma samples (n = 145) were obtained from HIV-positive MSM (HPTN 078). Samples were analysed using clinical assays (the ViroSeq HIV-1 Genotyping System and the Abbott RealTime HIV-1 Viral Load assay) and a research assay based on whole-genome NGS (veSEQ-HIV).

RESULTS

HIV protease and reverse transcriptase sequences (n = 142) and integrase sequences (n = 138) were obtained using ViroSeq. Sequences from all three regions were obtained for 100 (70.4%) of the 142 samples using veSEQ-HIV; results were obtained more frequently for samples with higher viral loads (93.5% for 93 samples with >5000 copies/mL; 50.0% for 26 samples with 1000-5000 copies/mL; 0% for 23 samples with <1000 copies/mL). For samples with results from both methods, drug resistance mutations (DRMs) were detected in 33 samples using ViroSeq and 42 samples using veSEQ-HIV (detection threshold: 5.0%). Overall, 146 major DRMs were detected; 107 were detected by both methods, 37 were detected by veSEQ-HIV only (frequency range: 5.0%-30.6%) and two were detected by ViroSeq only. HIV viral loads estimated by veSEQ-HIV strongly correlated with results from the Abbott RealTime Viral Load assay (R2 = 0.85; n = 142).

CONCLUSIONS

The NGS-based veSEQ-HIV method provided results for most samples with higher viral loads, was accurate for detecting major DRMs, and detected mutations at lower levels compared with a method based on population sequencing. The veSEQ-HIV method also provided HIV viral load data.

Risk of hearing loss among multidrug-resistant tuberculosis patients according to cumulative aminoglycoside dose

SETTING: The ototoxic effects of aminoglycosides (AGs) lead to permanent hearing loss, which is one of the devastating consequences of multidrug-resistant tuberculosis (MDR-TB) treatment. As AG ototoxicity is dose-dependent, the impact of a surrogate measure of AG exposure on AG-induced hearing loss warrants close attention for settings with limited therapeutic drug monitoring.OBJECTIVE: To explore the prognostic impact of cumulative AG dose on AG ototoxicity in patients following initiation of AG-containing treatment for MDR-TB.DESIGN: This prospective cohort study was nested within an ongoing cluster-randomized trial of nurse case management intervention across 10 MDR-TB hospitals in South Africa.RESULTS: The adjusted hazard of AG regimen modification due to ototoxicity in the high-dose group (≥75 mg/kg/week) was 1.33 times higher than in the low-dose group (<75 mg/kg/week, 95%CI 1.09-1.64). The adjusted hazard of developing audiometric hearing loss was 1.34 times higher than in the low-dose group (95%CI 1.01-1.77). Pre-existing hearing loss (adjusted hazard ratio [aHR] 1.71, 95%CI 1.29-2.26) and age (aHR 1.16 per 10 years of age, 95%CI 1.01-1.33) were also associated with an increased risk of hearing loss.CONCLUSION: MDR-TB patients with high AG dose, advanced age and pre-existing hearing loss have a significantly higher risk of AG-induced hearing loss. Those at high risk may be candidates for more frequent monitoring or AG-sparing regimens.

Community engagement and linkage to care efforts by peer community-health workers to increase PrEP uptake among sexual minority men

Purpose

Pre‐exposure prophylaxis (PrEP) prevents HIV yet uptake remains suboptimal across the United States. This paper evaluates the impact of outreach activities led by nurse supervised community healthcare workers (CHWs) on the PrEP care cascade.

Methods

This is an observational programmatic evaluation of LGBTQ + community outreach between March 1, 2016, to March 31, 2020, as part of a public health initiative. Descriptive statistics are used to characterize the data by outreach type.

Results

2,465 participants were reached. Overall, a PrEP appointment was scheduled for 94 (3.8%) with 70 (2.8%) confirmed to have completed a PrEP visit. Success for each type of community outreach activity was evaluated with virtual models outperforming face‐to‐face. Face‐to‐face outreach identified nine persons among 2,188 contacts (0.41%) completing an initial PrEP visit. The website prepmaryland.org identified 4 among 24 contacts (16.7%) and the PrEP telephone/text warm‐line identified 18 among 60 contacts (30%). The PrEPme smartphone application identified 39 among 168 contacts (23.2%).

Conclusions

Face‐to‐face community outreach efforts reached a large number of participants, yet had a lower yield in follow‐up and confirmed PrEP visits. All virtual platforms reached lower total numbers, but had greater success in attendance at PrEP visits, suggesting enhanced linkage to care.

Preparing the healthcare workforce in South Africa for short-course rifampicin-resistant TB treatment: inter-professional training and task-sharing considerations

BACKGROUND

Treatment for rifampicin-resistant Mycobacterium tuberculosis (RR-TB) is complex, however, shorter treatment, with newer antimicrobials are improving treatment outcomes. The South African National Department of Health (NDoH) recently accelerated the rollout of 9-month, all-oral, RR-TB short-course regimens. We sought to evaluate an inter-professional training program using pre-test and post-test performance of Professional Nurses (PNs), Advanced Practice Professional Nurses (APPNs) and Medical Officers (MOs) to inform: (a) training needs across cadres; (b) knowledge performance, by cadres; and (c) training differences in knowledge by nurse type.

METHODS

A 4-day didactic and case-based clinical decision support course for RR-TB regimens in South Africa (SA) was developed, reviewed and nationally accredited. Between February 2017 and July 2018, 12 training events were held. Clinicians who may initiate RR-TB treatment, specifically MOs and PN/APPNs with matched pre-post tests and demographic surveys were analyzed. Descriptive statistics are provided. Pre-post test evaluations included 25 evidence-based clinically related questions about RR-TB diagnosis, treatment, and care.

RESULTS

Participants (N = 842) participated in testing, and matched evaluations were received for 800 (95.0%) training participants. Demographic data were available for 793 (99.13%) participants, of whom 762 (96.1%) were MOs, or nurses, either PN or APPNs. Average correct response pre-test and post-test scores were 61.7% (range 7-24 correct responses) and 85.9% (range 12-25), respectively. Overall, 95.8% (730/762) of participants demonstrated improved knowledge. PNs improved on average 25% (6.22 points), whereas MOs improved 10% (2.89 points) with better mean test scores on both pre- and post-test (p < 0.000). APPNs performed the same as the MOs on post-test scores (p = NS).

CONCLUSIONS

The inter-professional training program in short-course RR-TB treatment improved knowledge for participants. MOs had significantly greater pre-test scores. Of the nurses, APPNs outperformed other PNs, and performed equally to MOs on post-test scores, suggesting this advanced cadre of nurses might be the most appropriate to initiate and monitor treatment in close collaboration with MOs. All cadres of nurse reported the need for additional clinical training and mentoring prior to managing such patients.

Aminoglycoside-induced Hearing Loss Among Patients Being Treated for Drug-resistant Tuberculosis in South Africa: A Prediction Model

BACKGROUND

Individuals treated for drug-resistant tuberculosis (DR-TB) with aminoglycosides (AGs) in resource-limited settings often experience permanent hearing loss, yet there is no practical method to identify those at higher risk. We sought to develop a clinical prediction model of AG-induced hearing loss among patients initiating DR-TB treatment in South Africa.

METHODS

Using nested, prospective data from a cohort of 379 South African adults being treated for confirmed DR-TB with AG-based regimens we developed the prediction model using multiple logistic regression. Predictors were collected from clinical, audiological, and laboratory evaluations conducted at the initiation of DR-TB treatment. The outcome of AG-induced hearing loss was identified from audiometric and clinical evaluation by a worsened hearing threshold compared with baseline during the 6-month intensive phase.

RESULTS

Sixty-three percent of participants (n = 238) developed any level of hearing loss. The model predicting hearing loss at frequencies from 250 to 8000 Hz included weekly AG dose, human immunodeficiency virus status with CD4 count, age, serum albumin, body mass index, and pre-existing hearing loss. This model demonstrated reasonable discrimination (area under the receiver operating characteristic curve [AUC] = 0.71) and calibration (χ2[8] = 6.10, P = .636). Using a cutoff of 80% predicted probability of hearing loss, the positive predictive value of this model was 83% and negative predictive value was 40%. Model discrimination was similar for ultrahigh-frequency hearing loss (frequencies >9000 Hz; AUC = 0.81) but weaker for clinically determined hearing loss (AUC = 0.60).

CONCLUSIONS

This model may identify patients with DR-TB who are at highest risk of developing AG-induced ototoxicity and may help prioritize patients for AG-sparing regimens in clinical settings where access is limited.

Leveraging nurse practitioner capacities to achieve global health for all: COVID-19 and beyond

Aim

To argue that nurse practitioners have been under‐utilized generally in the current global health environment, creating barriers to achieving universal health coverage and the Sustainable Development Goals.

Background

Nurse practitioners are advanced practice nurses possessing expert knowledge and leadership skills that can be optimized to narrow disparities and ensure access to high‐quality health care globally. Nurses worldwide have been challenged to meet global public health needs in the context of COVID‐19 (SARS‐CoV‐2 virus), and there are early indications that nurse practitioners are being called upon to the full extent of their capabilities in the current pandemic.

Sources of evidence

PubMed; Google Scholar; the International Council of Nurses; World Health Organization; United Nations; and the experiences of the authors.

Discussion

Several international reports, nursing and health organizations have called for continued investment in and development of nursing to improve mechanisms that promote cost‐effective and universally accessible care. Expanding nurse practitioner scopes of practice across nations will leverage their clinical capacities, policy and advocacy skills, and talents to lead at all levels.

Conclusion

Ongoing empirical data and policy change is needed to enable the full scope and strategic utilization of nurse practitioners across healthcare systems and contexts.

Implications for nursing practice, and nursing and health policy

Widespread education regarding nurse practitioner capacities for interdisciplinary partners, policymakers and the public is needed. Policies that safely expand their roles are critical. Role titles and remuneration reflective of their scope and service are required to lead, sustain and grow the workforce internationally.

Acceptability of self-collecting oropharyngeal swabs for sexually transmissible infection testing among men and women

In 2016, the rate of USA gonorrhoea and chlamydia cases increased by 18.6% and 6.9% respectively. Most people infected are asymptomatic and are not treated immediately, which negatively affects sexually transmissible infection (STI)/HIV rates. Men and women were asked to provide self-collected oropharyngeal specimens for STI testing (n = 79). Over 75% reported the collection of the swab was 'easy' or 'very easy' to use; 90% were willing to test for STIs at home in the future. Self-collecting oropharyngeal swabs for STI testing is acceptable among men and women. Future research should test the effect of self-collecting pharyngeal swabs on STI testing behaviours and results.

Prevalence of Pre-Existing Hearing Loss Among Patients With Drug-Resistant Tuberculosis in South Africa

Purpose Hearing loss, resulting from aminoglycoside ototoxicity, is common among patients with drug-resistant tuberculosis (DR-TB). Those with pre-existing hearing loss are at particular risk of clinically important hearing loss with aminoglycoside-containing treatment than those with normal hearing at baseline. This study aimed to identify factors associated with pre-existing hearing loss among patients being treated for DR-TB in South Africa. Method Cross-sectional analysis nested within a cluster-randomized trial data across 10 South African TB hospitals. Patients ≥ 13 years old received clinical and audiological evaluations before DR-TB treatment initiation. Results Of 936 patients, average age was 35 years. One hundred forty-two (15%) reported pre-existing auditory symptoms. Of 482 patients tested by audiometry, 290 (60%) had pre-existing hearing loss. The prevalence of pre-existing hearing loss was highest among patients ≥ 50 years (adjusted prevalence ratio [aPrR] for symptoms 5.53, 95% confidence interval (CI) [3.63, 8.42]; aPrR for audiometric hearing loss 1.63, 95% CI [1.31, 2.03] compared to age 13-18 years) and among those with a prior history of second-line TB treatment (aPrR for symptoms 1.73, 95% CI [1.66, 1.80]; PrR for audiometric hearing loss 1.33, 95% CI [1.03, 1.73]). Having HIV with cluster of differentiation 4 cell count < 200 cells/mm³ and malnutrition were risk factors but did not reach statistical significance in adjusted analyses. Conclusion Pre-existing hearing loss is common among patients presenting for DR-TB treatment in South Africa, and those older than the age of 50 years or who had prior second-line TB treatment history were at highest risk.

Nurse case management to improve the hepatitis C care continuum in HIV co-infection: Results of a randomized controlled trial

The opportunity to eliminate hepatitis C virus (HCV) is at hand, but challenges remain that negatively influence progress through the care continuum, particularly for persons co-infected with HIV who are not well engaged in care. We conducted a randomized controlled trial to test the effect of nurse case management (NCM) on the HCV continuum among adults co-infected with HIV compared to usual care (UC). Primary outcomes included linkage to HCV care (attendance at an HCV practice appointment within 60 days) and time to direct-acting antiviral (DAA) initiation (censored at 6 months). Sixty-eight participants were enrolled (NCM n = 35; UC n = 33). Participants were 81% Black/African American, 85% received Medicaid, 46% reported illicit drug use, 41% alcohol use, and 43% had an undetectable HIV viral load. At day 60, 47% of NCM participants linked to HCV care compared to 25% of UC participants (P = .031; 95% confidence bound for difference, 3.2%-40.9%). Few participants initiated DAAs (12% NCM; 25% UC). There was no significant difference in mean time to treatment initiation (NCM = 86 days; UC = 110 days; P = .192). Engagement in HCV care across the continuum was associated with drinking alcohol, knowing someone who cured HCV and having a higher CD4 cell count (P < .05). Our results support provision of NCM as a successful strategy to link persons co-infected with HIV to HCV care, but interventions should persist beyond linkage to care. Capitalizing on social networks, treatment pathways for patients who drink alcohol, and integrated substance use services may help improve the HCV care continuum.

Cardiovascular risk prevalence in South Africans with drug-resistant tuberculosis: a cross-sectional study

<sec id="st1"> <title>BACKGROUND</title> In South Africa, the risk factors for cardiovascular disease (CVD) are increasing, thereby impacting patients with drug-resistant tuberculosis (DR-TB). </sec> <sec id="st2"> <title>OBJECTIVE</title> To determine the prevalence of traditional CVD risk factors (diabetes mellitus [DM], smoking, hypertension, increased body mass index [BMI]) and a total risk score for CVD among patients with DR-TB. </sec> <sec id="st3"> <title>METHODS</title> This cross-sectional study was nested within an ongoing cluster-randomized trial in 10 DR-TB hospitals in South Africa. The data for the present study were collected between November 2014 and July 2016. </sec> <sec id="st4"> <title>RESULTS</title> Of 900 participants aged 18 years, 75.1% were co-infected with the human immunodeficiency virus (HIV), and 52.3% had one or more CVD risk factors. The prevalence of CVD risk factors was hypertension (16.7%), increased BMI (16.6%), DM (5.2%), and smoking (31.4%). Among patients with DM or hypertension, 58.8-95.5% had additional comorbid CVD risk factors. Of 398 participants eligible for the CVD risk score (age 35 years), 23.4% had a moderate or high CVD risk score. </sec> <sec id="st5"> <title>CONCLUSION</title> Patients with multiple diseases, including DR-TB and HIV, with traditional CVD risk factors, may have higher risks for negative outcomes during treatment for DR-TB. TB providers should identify people at risk to initiate primary and secondary prevention to improve outcomes. </sec>.

Management of the Patient With HIV/Hepatitis C Drug Interactions: A Guide for Nurses and Nurse Practitioners

Approximately one third of patients coinfected with HIV and hepatitis C virus (HCV) who initiate direct-acting antivirals (DAAs) for HCV treatment may have to switch antiretroviral therapy (ART) because of drug interactions. ART switches can negatively affect quality of life, increase HIV symptom burden, and delay HCV therapy. Approaches to identify ART/DAA drug interactions that minimize the impact of switching ART are urgently needed. Nurses can lead the way in addressing this new and major need. We provide a guide for registered nurses and nurse practitioners who care for patients coinfected with HIV and HCV to identify HIV/HCV drug interactions and manage ART/DAA coadministration when needed.

Evaluation of miLINC to shorten time to treatment for rifampicin-resistant Mycobacterium tuberculosis

BACKGROUND: Achieving the 90-90-90 targets for tuberculosis (TB) will require interventions that enhance diagnosis, linkage, treatment and adherence to care. As a first step in the process, our team designed a suite of smartphone applications known as miLINC to improve time from diagnosis to treatment initiation in drug-resistant TB patients.SETTING: Three clinical locations in a large, peri-urban district in KwaZulu-Natal, South Africa.OBJECTIVE: To assess the acceptability, feasibility and impact of the miLINC mobile health applications as a solution to reducing the time from presentation to treatment initiation of rifampicin-resistant (RR) TB patients.METHODS: We used a prospective, observational quality improvement evaluation of miLINC's impact among newly diagnosed patients with RR-TB.RESULTS: A convenience sample comprising details of 6341 patients with presumptive TB were entered into miLINC. Of the 631 TB-positive sputum specimens, 41 (6.5%) were found to be RR-TB. The mean time from clinical presentation to RR-TB treatment initiation was 3 days, 21 h, 17 min.CONCLUSION: This is the first study to suggest that the time from presentation to diagnosis and to treatment initiation for patients with RR-TB can be significantly improved using an integrated approach combining technology with appropriate human resources.

Increased risk of aminoglycoside-induced hearing loss in MDR-TB patients with HIV coinfection

SETTING

A high proportion of individuals with multidrug-resistant tuberculosis (MDR-TB) develop permanent hearing loss due to ototoxicity caused by injectable aminoglycosides (AGs). The prevalence of AG-induced hearing loss is greatest in tuberculosis (TB) and human immunodeficiency virus (HIV) endemic countries in sub-Saharan Africa. However, whether HIV coinfection is associated with a higher incidence of AG-induced hearing loss during MDR-TB treatment is controversial.

OBJECTIVE

To evaluate the impact of HIV coinfection on AG-induced hearing loss among individuals with MDR-TB in sub-Saharan Africa.

DESIGN

This was a meta-analysis of articles published in PubMed, Embase, Scopus, Cumulative Index to Nursing and Allied Health Literature, Web of Science, Cochrane Review, and reference lists using search terms 'hearing loss', 'aminoglycoside', and 'sub-Saharan Africa'.

RESULTS

Eight studies conducted in South Africa, Botswana and Namibia and published between 2012 and 2016 were included. As the included studies were homogeneous (χ2 = 8.84, df = 7), a fixed-effects model was used. Individuals with MDR-TB and HIV coinfection had a 22% higher risk of developing AG-induced hearing loss than non-HIV-infected individuals (pooled relative risk 1.22, 95%CI 1.10-1.36) during MDR-TB treatment.

CONCLUSION

This finding is critical for TB programs with regard to the expansion of injectable-sparing regimens. Our findings lend credibility to using injectable-sparing regimens and more frequent hearing monitoring, particularly in resource-limited settings for HIV-coinfected individuals.

Adverse outcome pathway for aminoglycoside ototoxicity in drug-resistant tuberculosis treatment

Individuals treated for multidrug-resistant tuberculosis (MDR-TB) with aminoglycosides (AGs) in resource-limited settings often experience permanent hearing loss. However, AG ototoxicity has never been conceptually integrated or causally linked to MDR-TB patients' pre-treatment health condition. We sought to develop a framework that examines the relationships between pre-treatment conditions and AG-induced hearing loss among MDR-TB-infected individuals in sub-Saharan Africa. The adverse outcome pathway (AOP) approach was used to develop a framework linking key events (KEs) within a biological pathway that results in adverse outcomes (AO), which are associated with chemical perturbation of a molecular initiating event (MIE). This AOP describes pathways initiating from AG accumulation in hair cells, sound transducers of the inner ear immediately after AG administration. After administration, the drug catalyzes cellular oxidative stress due to overproduction of reactive oxygen species. Since oxidative stress inhibits mitochondrial protein synthesis, hair cells undergo apoptotic cell death, resulting in irreversible hearing loss (AO). We identified the following pre-treatment conditions that worsen the causal linkage between MIE and AO: HIV, malnutrition, aging, noise, smoking, and alcohol use. The KEs are: (1) nephrotoxicity, pre-existing hearing loss, and hypoalbuminemia that catalyzes AG accumulation; (2) immunodeficiency and antioxidant deficiency that trigger oxidative stress pathways; and (3) co-administration of mitochondrial toxic drugs that hinder mitochondrial protein synthesis, causing apoptosis. This AOP clearly warrants the development of personalized interventions for patients undergoing MDR-TB treatment. Such interventions (i.e., choosing less ototoxic drugs, scheduling frequent monitoring, modifying nutritional status, avoiding poly-pharmacy) will be required to limit the burden of AG ototoxicity.

Preferences for an HIV prevention mobile phone app: a qualitative study among men who have sex with men in China

BACKGROUND

Men who have sex with men (MSM) have a disproportionate burden of HIV infection. Mobile phone apps provide a promising means of improving HIV prevention among MSM. But this has received little examination in China. The objective of this study was to explore MSM's preferences for an HIV prevention mobile phone app.

METHODS

Qualitative semi-structured personal interviews were conducted with 19 MSM to determine their preferences for features and content to inform the design of an app aimed at HIV prevention in China.

RESULTS

Five categories were identified under the main category preferences for features of the app: target population, attributes, language used, potential user access, and perceived usefulness. Five categories were identified under the main category preferences for content of the app: functions to facilitate HIV testing behavior, HIV post-exposure prevention, warning against substance use, psychological support, and areas for communication.

CONCLUSIONS

Findings suggest that the design of an app targeting MSM in China should use an integrated framework addressing behavioral and psychological aspects, satisfy common needs of potential users, avoid perpetuating negative stereotypes and stigma, and avoid possible increase of risk behavior due to using the app.

Improvements in the HIV care continuum needed to meaningfully reduce HIV incidence among men who have sex with men in Baltimore, US: a modelling study for HPTN 078

INTRODUCTION

HIV prevalence is high among men who have sex with men (MSM) in Baltimore, Maryland, United States, and the levels of viral suppression among HIV-positive MSM are relatively low. The HIV Prevention Trials Network 078 trial seeks to increase the levels of viral suppression among US MSM by increasing the rates of diagnosis and linkage to care and treatment. We estimated the increases in viral suppression needed to reach different HIV incidence reduction targets, and the impact of meeting diagnosis and treatment targets.

METHODS

We used a mathematical model of HIV transmission among MSM from Baltimore, US, parameterised with behavioural data and fitted to HIV prevalence and care continuum data for Baltimore wherever possible, to project increases in viral suppression needed to reduce the HIV incidence rate among Baltimore MSM by 10, 20, 30 or 50% after 2, 5 and 10 years. We also projected HIV incidence reductions achieved if US national targets - 90% of people living with HIV (PLHIV) know their HIV serostatus, 90% of those diagnosed are retained in HIV medical care and 80% of those diagnosed are virally suppressed - or UNAIDS 90-90-90 targets (90% of PLHIV know their status, 90% of those diagnosed receive antiretroviral therapy (ART), 90% of those receiving ART are virally suppressed) are each met by 2020.

RESULTS

To reduce the HIV incidence rate by 20% and 50% after five years (compared with the base-case at the same time point), the proportion of all HIV-positive MSM who are virally suppressed must increase above 2015 levels by a median 13 percentage points (95% uncertainty interval 9 to 16 percentage points) from median 49% to 60%, and 27 percentage points (22 to 35) from 49% to 75% respectively. Meeting all three US or 90-90-90 UNAIDS targets results in a 48% (31% to 63%) and 51% (38% to 65%) HIV incidence rate reduction in 2020 respectively.

CONCLUSIONS

Substantial improvements in levels of viral suppression will be needed to achieve significant incidence reductions among MSM in Baltimore, and to meet 2020 US and UNAIDS targets. Future modelling studies should additionally consider the impact of pre-exposure prophylaxis for MSM.

Siyaphambili protocol: An evaluation of randomized, nurse-led adaptive HIV treatment interventions for cisgender female sex workers living with HIV in Durban, South Africa

In South Africa, 60% of female sex workers are estimated to be living with human immunodeficiency virus (HIV). Many of these women face structural and individual-level barriers to initiating, accessing, and adhering to antiretroviral therapy (ART). While data are limited, it is estimated that less than 40% of sex workers living with HIV achieve viral suppression, leading to suboptimal clinical outcomes and sustained risks of onward sexual and vertical HIV transmission. Siyaphambili, a NINR/NIH-funded study, focuses on studying optimal implementation strategies for meeting HIV treatment needs among cisgender female sex workers living with HIV who are not virally suppressed. Here, we present the study protocol of this sequential multiple assignment randomized trial. In total, 800 viremic female sex workers will be enrolled into an 18-month adaptive implementation study to 1) compare the effectiveness and durability of a nurse-led decentralized ART treatment program versus an individualized case management approach, in isolation or in combination to achieve viral suppression and 2) estimate incremental cost-effectiveness of interventions and combinations of interventions. The primary outcome is a combined intention-to-treat outcome of retention in ART care and viral suppression at 18 months with secondary implementation outcomes. Siyaphambili aims to inform the implementation of and scale-up of HIV treatment services for female sex workers by determining the minimal package of services needed to achieve viral suppression and by characterizing individuals in need of more intensive HIV treatment approaches.

Provision of guideline-based care for drug-resistant tuberculosis in South Africa: Level of concordance between prescribing practices and guidelines

TITLE

Provision of guideline-based care for drug-resistant tuberculosis in South Africa: Level of concordance between prescribing practices and guidelines.

OBJECTIVE

We examined the influence of individual and site characteristics on the concordance between prescribed treatment regimens and recommended standardized regimen according to national guidelines for patients with drug-resistant tuberculosis (DR-TB) in South Africa.

METHODS

Participants were 337 youth and adults treated for DR-TB between November 2014 and August 2016 at ten DR-TB treatment sites in Eastern Cape and KwaZulu Natal provinces, South Africa. Logistic regression was used to determine individual and system characteristics related to concordance at treatment initiation between the prescribed treatment regimens in terms of medication composition, dosage, and frequency and guideline-based standardized regimen that included four oral and one injectable medications.

RESULTS

The sample was 19% (n = 64) youth (15-24 years), 53% (n = 179) male, 73% (n = 243) HIV coinfected, and 51% (n = 169) with prior history of TB treatment. Guideline medications were correctly prescribed for 88% (n = 295) of patients, but only 33% (n = 103) received the correct medications and doses. Complete guideline adherence to medications, doses, and frequency was achieved for 30% (n = 95) of patients. Younger age, HIV coinfection, and rural treatment setting were associated with the prescription of correct medications.

CONCLUSION

Most individuals are prescribed the correct DR-TB medications, yet few individuals receive correct medications, dosages, and frequencies. Further study is needed to examine the root causes for treatment guideline deviations and opportunities for improvement.

Effectiveness of macronutrient supplementation on nutritional status and HIV/AIDS progression: A systematic review and meta-analysis

BACKGROUND & AIMS

Malnutrition is common in Sub-Saharan Africa, weakening the immune function of persons living with HIV infection (PLWH). Being malnourished at the initiation of antiretroviral therapy (ART) leads to higher risk of early mortality and reduced quality of life. Thus, introduction of protein-energy-fortified macronutrient supplements at ART initiation may improve HIV treatment outcomes. This review aimed to evaluate the effectiveness of macronutrient interventions.

METHODS

This systematic review and meta-analysis included 15 studies conducted from 2000 to 2015 among Sub-Saharan African adults.

RESULTS

Six randomized controlled trials and 4 retrospective cohort studies provided data eligible for a meta-analysis. Supplementation significantly increased the overall standardized mean difference (SMD) between baseline and follow-up data in weight (SMD = 0.382, p < .001), BMI (SMD = 0.799, p < .001); fat-free mass (SMD = 0.154, p = .009); and CD4 count (SMD = 0.428, p < .001).

CONCLUSION

Protein-energy-fortified macronutrient supplementation at ART initiation may positively influence nutritional status and immunologic response in PLWH in Sub-Saharan Africa.

Care2Cure: A randomized controlled trial protocol for evaluating nurse case management to improve the hepatitis C care continuum within HIV primary care

Co-infection with HIV and hepatitis C virus (HCV) results in a threefold increase in relative risk of progression to end stage liver disease and cirrhosis compared to HCV alone. Although curative treatments exist, less than one quarter of people with HCV are linked to care, and even fewer have received treatment. The Care2Cure study is a single-blinded, randomized controlled trial to improve the HCV care continuum among people co-infected with HIV. This ongoing study was designed to test whether a nurse case management intervention can (i) improve linkage to HCV care and (ii) decrease time to HCV treatment initiation among 70 adults co-infected with HIV who are not engaged in HCV care. The intervention is informed by the Andersen Behavioral Model of Health Services Use and consists of nurse-initiated referral, strengths-based education, patient navigation, appointment reminders, and care coordination for drug-drug interactions in the setting of HIV primary care. Validated instruments are used to measure participant characteristics including HCV knowledge, substance use, and depression. The primary outcome is linkage to HCV care (yes/no) within 60 days. In this protocol paper, we describe the first clinical trial to examine the effects of a nurse case management intervention to improve the HCV care continuum among people co-infected with HIV/HCV in the era of all-oral HCV treatment. We describe our work in progress, challenges encountered, and strategies to engage this hard-to-reach population.

A systematic review of the effectiveness of smoking cessation interventions among patients with tuberculosis

Smoking is a significant risk factor for morbidity and mortality, particularly among patients with tuberculosis (TB). Although smoking cessation is recommended by the World Health Organization and the International Union Against Tuberculosis and Lung Disease, there has been no published evaluation of smoking cessation interventions among people with TB. The purpose of this review was to synthesize the evidence on interventions and suggest practice, research and policy implications. A systematic review of the literature identified 14 peer-reviewed studies describing 13 smoking cessation interventions between 2007 and 2017. There were five randomized controlled trials, three non-randomized interventions, and five prospective cohort studies. The primary types of interventions were brief advice (n = 9), behavioral counseling (n = 4), medication (n = 3), and community-based care (n = 3). A variety of health care workers (HCWs) implemented interventions, from physicians, nurses, clinic staff, community health workers (CHWs), as did family members. There was significant heterogeneity of design, definition of smoking and smoking abstinence, and implementation, making comparison across studies difficult. Although all smoking interventions increased smoking cessation between 15% and 82%, many studies had a high risk for bias, including six without a control group. The implementing personnel did not make a large difference in cessation results, suggesting that national TB programs may customize according to their needs and limitations. Family members may be important supporters/advocates for cessation. Future research should standardize definitions of smoking and cessation to allow comparisons across studies. Policy makers should encourage collaboration between tobacco and TB initiatives and develop smoking cessation measures to maximize results in low-resource settings.

Community health worker interventions to promote psychosocial outcomes among people living with HIV-A systematic review

Background

Community health worker (CHW) interventions are a successful strategy to promote health among HIV-negative and persons living with HIV (PLWH). Psychosocial factors are critical dimensions of HIV/AIDS care contributing to prognosis of the disease, yet it is unclear how CHW interventions improve psychosocial outcomes in PLWH. The purpose of this study was to critically appraise the types, scope, and nature of CHW interventions designed to address psychosocial outcomes in PLWH.

Methods

We performed database searches—PubMed, EMBASE, CINAHL, and Cochrane—to identify randomized controlled trials published in English before April 2017. Fourteen articles met the eligibility criteria.

Results

Half of the studies were conducted in the United States. Social cognitive theory was used more than once in nine theory-guided studies. CHW interventions were largely focused on reducing depression (n = 6) or stigma related to HIV (n = 4), or promoting quality of life (n = 4), social support (n = 4), and self-efficacy (n = 4). Didactic methods and role-playing were used to train CHWs. CHWs played multiple roles in delivering intervention, including a counselor and a supporter (n = 10), educator (n = 5), or a navigator (n = 3). CHW intervention fidelity was assessed in 4 studies. Five studies found positive changes in six psychosocial outcomes including quality of life (2 of 4) and self-efficacy (2 of 4). CHW interventions had no effect on social support in 2 of 4 studies, and stigma in 3 of 4 studies. None of the CHW interventions were successful in reducing depressive symptoms among PLWH.

Conclusions

Evidence partially supported the use of CHWs in promoting psychosocial outcomes in PLWH. Future CHW intervention should be expanded in scope to address key psychosocial determinants of HIV/AIDS outcomes such as health literacy. Further, fidelity measures should be incorporated into intervention delivery.

Barriers to tuberculosis and human immunodeficiency virus treatment guidelines adherence among nurses initiating and managing anti-retroviral therapy in KwaZulu-Natal and North West provinces

BACKGROUND

 Nurses, as front-line care providers in the South Africa's health care system, are called upon to deliver integrated interventions for tuberculosis and human immunodeficiency virus (TB and HIV) including nurse-initiated management of anti-retroviral therapy (NIMART) and anti-TB treatment. Adherence to treatment guidelines and factors associated with non-adherence to treatment guidelines among nurses remain under explored.

PURPOSE

 To explore and describe barriers to treatment guidelines adherence among nurses initiating and managing anti-retroviral therapy and anti-TB treatment in KwaZulu-Natal and North West provinces.

DESIGN

 This study employed a qualitative exploratory descriptive design.

METHODS

 Four semi-structured focus group interviews were conducted during 2014 each consisting of four to eight NIMART trained nurses. Audiotaped interviews were transcribed verbatim and analysed using Atlas T.I. software.

FINDINGS

 During data analysis, two themes emerged: (1) NIMART trained nurses' distress about TB and HIV guidelines adherence that is inclusive of lack of agreement with guidelines, poor motivation to implement guidelines, poor clinical support and supervision, resistance to change, insufficient knowledge or lack of awareness and (2) exterior factors inhibiting nurses' adherence to treatment guidelines which incorporated organisational factors, guidelines-related factors and patient-related factors.

CONCLUSION

 This qualitative study identified that nurses have substantial concerns over guideline adherence. If NIMART trained nurses' barriers inhibiting adherence to treatment guidelines cannot be remedied, patient outcomes may suffer and South Africa will struggle to meet the 90-90-90 targets.