Articles tagged as "Health care delivery"

Closing the HIV testing gap with partner-delivered self-testing

Promoting partner testing and couples testing through secondary distribution of HIV self-tests: a randomized clinical trial.

Masters SH, Agot K, Obonyo B, Napierala Mavedzenge S, Maman S, Thirumurthy H. PLoS Med. 2016 Nov 8;13(11):e1002166. doi: 10.1371/journal.pmed.1002166. eCollection 2016.

Background: Achieving higher rates of partner HIV testing and couples testing among pregnant and postpartum women in sub-Saharan Africa is essential for the success of combination HIV prevention, including the prevention of mother-to-child transmission. We aimed to determine whether providing multiple HIV self-tests to pregnant and postpartum women for secondary distribution is more effective at promoting partner testing and couples testing than conventional strategies based on invitations to clinic-based testing.

Methods and findings: We conducted a randomized trial in Kisumu, Kenya, between June 11, 2015, and January 15, 2016. Six hundred antenatal and postpartum women aged 18-39 y were randomized to an HIV self-testing (HIVST) group or a comparison group. Participants in the HIVST group were given two oral-fluid-based HIV test kits, instructed on how to use them, and encouraged to distribute a test kit to their male partner or use both kits for testing as a couple. Participants in the comparison group were given an invitation card for clinic-based HIV testing and encouraged to distribute the card to their male partner, a routine practice in many health clinics. The primary outcome was partner testing within 3 mo of enrollment. Among 570 participants analyzed, partner HIV testing was more likely in the HIVST group (90.8%, 258/284) than the comparison group (51.7%, 148/286; difference = 39.1%, 95% CI 32.4% to 45.8%, p < 0.001). Couples testing was also more likely in the HIVST group than the comparison group (75.4% versus 33.2%, difference = 42.1%, 95% CI 34.7% to 49.6%, p < 0.001). No participants reported intimate partner violence due to HIV testing. This study was limited by self-reported outcomes, a common limitation in many studies involving HIVST due to the private manner in which self-tests are meant to be used.

Conclusions: Provision of multiple HIV self-tests to women seeking antenatal and postpartum care was successful in promoting partner testing and couples testing. This approach warrants further consideration as countries develop HIVST policies and seek new ways to increase awareness of HIV status among men and promote couples testing.

Trial registration: ClinicalTrials.gov NCT02386215.

Abstract  Full-text [free] access 

Editor’s notes: Despite scale-up of HIV testing services, two in every five people living with HIV remain undiagnosed. World Health Organization (WHO) has just issued updated guidance on HIV testing services (HTS). In an effort to plug this testing gap, it strengthened the recommendation that HIV self-testing (HIVST) should be offered as one of the approaches to HTS. This paper adds to the body of evidence supporting that recommendation and provides more insight into the specific role of partner-delivered self-testing.     

There are challenges with conducting clinical trials of HIVST, one of which is selecting an appropriate outcome measure. In this trial, the primary outcome was participant report of male partner testing within three months of enrolment. Overall, uptake of male partner testing as reported by the participants was surprisingly high. It is worth noting that the participants and their partners may not have been particularly hard-to-reach groups. Almost all were married. The female participants were frequent testers. On average, they had tested three times in the past year. Most participants also reported that their male partner had tested at least once in the past year. It should also be noted that many women that were screened chose not to participate, so the participants may have to some extent pre-selected themselves as more interested and more likely to benefit from the activity.   

There were very few male partners reported as testing HIV positive during follow-up. This study was not able to determine how effectively people linked to care after HIVST. This is one of a number of research questions that remain around the delivery and impact of HIVST. Many of these are being addressed by the large HIV Self-Testing Africa (STAR) Project (http://hivstar.lshtm.ac.uk/). What seems to be beyond debate now though is that HIVST can and should play a role in helping us to achieve the UNAIDS 90-90-90 treatment target.   

Africa
Kenya
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Poor adherence during the first three months post-delivery among women on Option B+

Adherence to antiretroviral therapy during and after pregnancy: cohort study on women receiving care in Malawi's Option B+ program.

Haas AD, Msukwa MT, Egger M, Tenthani L, Tweya H, Jahn A, Gadabu OJ, Tal K, Salazar-Vizcaya L, Estill J, Spoerri A, Phiri N, Chimbwandira F, van Oosterhout JJ, Keiser O. Clin Infect Dis. 2016 Nov 1;63(9):1227-1235. Epub 2016 Jul 26.

Background: Adherence to antiretroviral therapy (ART) is crucial to preventing mother-to-child transmission of human immunodeficiency virus (HIV) and ensuring the long-term effectiveness of ART, yet data are sparse from African routine care programs on maternal adherence to triple ART.

Methods: We analyzed data from women who started ART at 13 large health facilities in Malawi between September 2011 and October 2013. We defined adherence as the percentage of days "covered" by pharmacy claims. Adherence of ≥90% was deemed adequate. We calculated inverse probability of censoring weights to adjust adherence estimates for informative censoring. We used descriptive statistics, survival analysis, and pooled logistic regression to compare adherence between pregnant and breastfeeding women eligible for ART under Option B+, and nonpregnant and nonbreastfeeding women who started ART with low CD4 cell counts or World Health Organization clinical stage 3/4 disease.

Results: Adherence was adequate for 73% of the women during pregnancy, for 66% in the first 3 months post partum, and for about 75% during months 4-21 post partum. About 70% of women who started ART during pregnancy and breastfeeding adhered adequately during the first 2 years of ART, but only about 30% of them had maintained adequate adherence at every visit. Risk factors for inadequate adherence included starting ART with an Option B+ indication, at a younger age, or at a district hospital or health center.

Conclusions: One-third of women retained in the Option B+ program adhered inadequately during pregnancy and breastfeeding, especially soon after delivery. Effective interventions to improve adherence among women in this program should be implemented.

Abstract  Full-text [free] access

Editor’s notes: To maximize the impact of antiretroviral therapy (ART), people living with HIV should be diagnosed early, enrolled and retained in pre-ART care, initiated on ART and retained in ART care.  Long-term adherence to achieve and maintain viral load suppression is the last step in the continuum of HIV care.

“Option B+” is the programmatic option for preventing mother-to-child HIV transmission, pioneered by Malawi, in which combination ART is started during pregnancy and continued life-long. This manuscript describes adherence to ART among pregnant women in the Option B+ programme in Malawi. The authors had access to prospectively-collected pharmacy data, and created an adherence measure that estimates the percentage of days ARVs were actually available to women during a time period. Therefore, this indicator measures the maximum number of days that ART could have been taken, but does not measure how much of the treatment was actually consumed. In this study, about a quarter of women started on ART with an Option B+ indication were lost to follow-up during the first year of ART. Among women retained, 30% adhered inadequately during pregnancy and breastfeeding, especially during the first three months after delivery. Unreported transfers of care to other clinics after delivery, postnatal depression, or difficulties with travelling to the facilities may be explanations for this temporary decline in adherence.

The authors validated their pharmacy-based adherence measure against viral load data in a subsample of about 500 people. They found that their adherence measure correlated well with the viral load measurement, and suggest that if access to viral load testing is limited, pharmacy-based adherence measures might be useful to identify people with adherence problems for targeted viral load testing.

These data are consistent with other studies reporting suboptimal retention particularly among women starting ART during pregnancy. Suboptimal adherence to ART during breastfeeding increases the risk of post-natal transmission, and the risk of the emergence of resistant virus in both mother and infant, as well as compromising the mother’s treatment outcome. Programmes need to address these issues in order to support adherence and retention in the early post-natal period. 

Africa
Malawi
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How to keep HIV prevalence low in refugee populations

Predictors of HIV infection: a prospective HIV screening study in a Ugandan refugee settlement.

O'Laughlin KN, Rabideau DJ, Kasozi J, Parker RA, Bustamante ND, Faustin ZM, Greenwald KE, Walensky RP, Bassett IV. BMC Infect Dis. 2016 Nov 23;16(1):695.

Background: The instability faced by refugees may place them at increased risk of exposure to HIV infection. Nakivale Refugee Settlement in southwestern Uganda hosts  68 000 refugees from 11 countries, many with high HIV prevalence. We implemented an HIV screening program in Nakivale and examined factors associated with new HIV diagnosis.

Methods: From March 2013-November 2014, we offered free HIV screening to all clients in the Nakivale Health Center while they waited for their outpatient clinic visit. Clients included refugees and Ugandan nationals accessing services in the settlement. Prior to receiving the HIV test result, participants were surveyed to obtain demographic information including gender, marital status, travel time to reach clinic, refugee status, and history of prior HIV testing. We compared variables for HIV-infected and non-infected clients using Pearson's chi-square test, and used multivariable binomial regression models to identify predictors of HIV infection.

Results: During the HIV screening intervention period, 330 (4%) of 7766 individuals tested were identified as HIV-infected. Refugees were one quarter as likely as Ugandan nationals to be HIV-infected (aRR 0.27 [0.21, 0.34], p < 0.0001). Additionally, being female (aRR 1.43 [1.14, 1.80], p = 0.002) and traveling more than 1 h to the clinic (aRR 1.39 [1.11, 1.74], p = 0.003) increased the likelihood of being HIV-infected. Compared to individuals who were married or in a stable relationship, being divorced/separated/widowed increased the risk of being HIV-infected (aRR 2.41 [1.88, 3.08], p < 0.0001), while being single reduced the risk (aRR 0.60 [0.41, 0.86], p < 0.0001). Having been previously tested for HIV (aRR 0.59 [0.47, 0.74], p < 0.0001) also lowered the likelihood of being HIV-infected.

Conclusions: In an HIV screening program in a refugee settlement in Uganda, Ugandan nationals are at higher risk of having HIV than refugees. The high HIV prevalence among clients seeking outpatient care, including Ugandan nationals and refugees, warrants enhanced HIV screening services in Nakivale and in the surrounding region. Findings from this research may be relevant for other refugee settlements in sub-Saharan Africa hosting populations with similar demographics, including the 9 other refugee settlements in Uganda.

Abstract  Full-text [free] access 

Editor’s notes: The 4% prevalence seen among refugees in this study warrants the introduction of a routine offer of HIV testing and counselling, provider-initiated testing and counselling (PITC), in the outpatient services provided at this refugee settlement in Uganda. Although 7766 people accepted the offer of HIV testing and counselling (HTC), the real extent of the acceptability of this service is unclear because routine service delivery records document simply encounters (23 016 during the study period) rather than unique individuals. There may be challenges in defining and using unique identifiers in refugee settlement health care services but this is one example of their potential utility in helping understand the true burden of disease in these settings. HIV prevalence in refugees accepting testing was not significantly different from that in the general population in their countries of origin. For example, Rwanda 2.3% versus 2.9% and Burundi 1.4% versus 1.0%. The exception was the Democratic Republic of Congo (DRC) with 1.9% of Congolese refugees being HIV-positive compared to 0.8% in the DRC general population, warranting further study to understand this increased HIV risk.

This study reveals lower HIV prevalence among refugees (2%) than among Ugandan nationals availing themselves of the settlement health services (9%). The Ugandans included both refugees and people living in surrounding communities. Ugandans freely come and go from the settlement for job-associated or personal reasons. People testing positive for HIV were more likely to live outside the settlement. The extent of sexual mixing between local Ugandans and refugees from other countries in Nakivale is unknown but providing prevention and treatment services to both populations could help reduce the risk of HIV transmission within the settlement. This study was conducted when the 2010 WHO guidelines of 350 cells/mm3 or WHO stage III/IV for treatment initiation were in effect and antiretroviral therapy was free of charge. However, data are not presented in this paper on the important question of the extent of linkage to care and antiretroviral therapy. These data are now being used worldwide to track progress towards the UNAIDS 90-90-90 treatment target. Refugee settlements in sub-Saharan Africa provide fertile settings for a routine offer of HIV testing and immediate offer of antiretroviral therapy to people found to be HIV-positive, as per current WHO guidelines. This would benefit not only these individuals clinically but would help keep HIV transmission as low as possible in refugee settlements.

Africa
Uganda
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‘I wish I could have a life like others’: mental health challenges for young people living with HIV in Tanzania

A qualitative exploration of the mental health and psychosocial contexts of HIV-positive adolescents in Tanzania.

Ramaiya MK, Sullivan KA, K OD, Cunningham CK, Shayo AM, Mmbaga BT, Dow DE. PLoS One. 2016 Nov 16;11(11):e0165936. doi: 10.1371/journal.pone.0165936. eCollection 2016.

Although 85% of HIV-positive adolescents reside in sub-Saharan Africa, little is known about the psychosocial and mental health factors affecting their daily well-being. Identifying these contextual variables is key to development of culturally appropriate and effective interventions for this understudied and high-risk population. The purpose of this study was to identify salient psychosocial and mental health challenges confronted by HIV-positive youth in a resource-poor Tanzanian setting. A total of 24 qualitative interviews were conducted with a convenience sample of adolescents aged 12-24 receiving outpatient HIV care at a medical center in Moshi, Tanzania. All interviews were audio-recorded, transcribed, and coded using thematic analysis. Psychosocial challenges identified included loss of one or more parents, chronic domestic abuse, financial stressors restricting access to medical care and education, and high levels of internalized and community stigma among peers and other social contacts. Over half of youth (56%) reported difficulties coming to terms with their HIV diagnosis and espoused related feelings of self-blame. These findings highlight the urgent need to develop culturally proficient programs aimed at helping adolescents cope with these manifold challenges. Results from this study guided the development of Sauti ya Vijana (The Voice of Youth), a 10-session group mental health intervention designed to address the psychosocial and mental health needs of HIV-positive Tanzanian youth.

Abstract  Full-text [free] access 

Editor’s notes: This article presents the findings of a mixed-methods study with young people living with HIV and accessing care in Moshi, Tanzania. The study was conducted as part of a larger study assessing mental health needs in this population. The article reports on themes from individual qualitative interviews with 24 young people (aged 13-23) who had mental health difficulties that were previously assessed with the scales used in the larger project. Young people reported a wide range of psychosocial issues leading to ongoing mental health challenges.  These were challenges for which they had received little or no psychological support. Issues included internalized, feared and experienced HIV stigma, loss and bereavement from being orphaned.  Additional challenges were stress from poverty and insecurity in the household, isolation and difficulties with disclosure of their HIV status, and direct and vicarious experiences of violence and abuse. Young people also discussed finding strength in spirituality, friendships and especially peer-support from other young people living with HIV. Findings from the overall study are being used to inform the development of a mental health activity model that, if effective, could be scaled up in other low-income settings. 

Africa
United Republic of Tanzania
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Moving from facility to community-based models of HIV care - will it work?

Community-based interventions to improve and sustain antiretroviral therapy adherence, retention in HIV care and clinical outcomes in low- and middle-income countries for achieving the UNAIDS 90-90-90 targets.

Nachega JB, Adetokunboh O, Uthman OA, Knowlton AW, Altice FL, Schechter M, Galarraga O, Geng E, Peltzer K, Chang LW, Van Cutsem G, Jaffar SS, Ford N, Mellins CA, Remien RH, Mills EJ. Curr HIV/AIDS Rep. 2016 Oct;13(5):241-55. doi: 10.1007/s11904-016-0325-9.

Little is known about the effect of community versus health facility-based interventions to improve and sustain antiretroviral therapy (ART) adherence, virologic suppression, and retention in care among HIV-infected individuals in low- and middle-income countries (LMICs). We systematically searched four electronic databases for all available randomized controlled trials (RCTs) and comparative cohort studies in LMICs comparing community versus health facility-based interventions. Relative risks (RRs) for pre-defined adherence, treatment engagement (linkage and retention in care), and relevant clinical outcomes were pooled using random effect models. Eleven cohort studies and eleven RCTs (N = 97 657) were included. Meta-analysis of the included RCTs comparing community- versus health facility-based interventions found comparable outcomes in terms of ART adherence (RR = 1.02, 95 % CI 0.99 to 1.04), virologic suppression (RR = 1.00, 95 % CI 0.98 to 1.03), and all-cause mortality (RR = 0.93, 95 % CI 0.73 to 1.18). The result of pooled analysis from the RCTs (RR = 1.03, 95 % CI 1.01 to 1.06) and cohort studies (RR = 1.09, 95 % CI 1.03 to 1.15) found that participants assigned to community-based interventions had statistically significantly higher rates of treatment engagement. Two studies found community-based ART delivery model either cost-saving or cost-effective. Community- versus facility-based models of ART delivery resulted in at least comparable outcomes for clinically stable HIV-infected patients on treatment in LMICs and are likely to be cost-effective.

Abstract access  

Editor’s notes: The remarkable global scale-up of antiretroviral therapy (ART) programmes, while much-needed and impressive, has had inevitable consequences. These include overcrowding of health facilities, longer waiting times, reduced time for counselling and care of newly-enrolled people and restricted capacity to provide support for people who do not remain engaged with care. Furthermore, the UNAIDS 90-90-90 treatment target for 2020 to have 90% of people living with HIV know their HIV status, 90% of all diagnosed individuals receiving ART and 90% of people living with HIV on ART to be virally suppressed, will now require an additional 20 million people living with HIV to start treatment.

Community-based programmes to complement facility-based model of HIV care delivery are increasingly being recognised as an important and sustainable approach to address the growing numbers of people accessing care in high-HIV prevalence settings. This review compared outcomes of community-based versus facility-based models of ART delivery and treatment support. There was no statistical difference in optimal ART adherence, virologic suppression or all-cause mortality between participants assigned to community-based ART and facility-based ART in randomised controlled trials (RCTs). When data from RCTs and cohort studies were pooled, participants assigned to community-based ART appeared to have higher rates of retention in care at the end of the follow-up period. Notably, the few studies that did examine cost-effectiveness found community-based programmes to be cost-saving.

The findings demonstrate that community-level programmes are certainly not inferior to facility-based programmes. However, it is important to note some key limitations. Firstly, many of the studies are subject to selection bias, i.e. people at risk of poorer outcomes e.g. sicker people or people with a history of poor adherence may be excluded from receiving community-based programmes. The authors also highlight a high risk of “other forms of bias” in the cohort studies, but these are not specified. Secondly, adherence measures based on self-report may not be reliable. Thirdly, the review compared a heterogeneous set of programmes. Fourthly, as with other systematic reviews, publication bias is highly likely.   

Notwithstanding these limitations, this study suggests that community-based programmes have promise in supporting fragile and overcrowded facility-based healthcare systems in providing HIV care to a growing number of people. There may even be potential for integrating HIV care with care for other chronic conditions.

Well-designed studies are necessary, given the ambitious targets we have set ourselves, to explore the effectiveness and cost-effectiveness of community-based programmes. This is particularly important in under-represented groups with disproportionately poor outcomes such as children, adolescents and pregnant women. Further, for community-based programmes to be effective, it will be critical to ensure that adequate training and mentorship and ongoing monitoring for quality assurance is in place.      

Africa, Asia, Latin America
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Community ART support groups: a partial solution for improving retention in care?

A decade of antiretroviral therapy scale-up in Mozambique: evaluation of outcome trends and new models of service delivery among more than 300 000 patients enrolled during 2004-2013.

Auld AF, Shiraishi RW, Couto A, Mbofana F, Colborn K, Alfredo C, Ellerbrock TV, Xavier C, Jobarteh K. J Acquir Immune Defic Syndr. 2016 Oct 1;73(2):e11-22. doi: 10.1097/QAI.0000000000001137.

Background: During 2004-2013 in Mozambique, 455 600 HIV-positive adults (≥15 years old) initiated antiretroviral therapy (ART). We evaluated trends in patient characteristics and outcomes during 2004-2013, outcomes of universal treatment for pregnant women (Option B+) implemented since 2013, and effect on outcomes of distributing ART to stable patients through Community ART Support Groups (CASG) since 2010.

Methods: Data for 306 335 adults starting ART during 2004-2013 at 170 ART facilities were analyzed. Mortality and loss to follow-up (LTFU) were estimated using competing risks models. Outcome determinants were estimated using proportional hazards models, including CASG participation as a time-varying covariate.

Results: Compared with ART enrollees in 2004, enrollees in 2013 were more commonly female (55% vs. 73%), more commonly pregnant if female (<1% vs. 30%), and had a higher median baseline CD4 count (139 vs. 235/µL). During 2004-2013, observed 6-month mortality declined from 7% to 2% but LTFU increased from 24% to 30%. Pregnant women starting ART with CD4 count >350/µL and WHO stage I/II under Option B+ guidelines in 2013 had low 6-month mortality (0.1%) but high 6-month LTFU (38%). During 2010-2013, 6766 patients joined CASGs. In multivariable analysis, compared with nonparticipation in CASG, CASG participation was associated with 35% lower LTFU but similar mortality.

Conclusions: Initiation of ART at earlier disease stages in later calendar years might explain observed declines in mortality. Retention interventions are needed to address trends of increasing LTFU overall and the high LTFU among Option B+ pregnant women specifically. Further expansion of CASG could help reduce LTFU.

Abstract access  

Editor’s notes: The UNAIDS 90–90–90 treatment target for 2020 calls for 90% of all people with HIV to be diagnosed, 90% of people with HIV diagnosed to receive ART and 90% of people on ART to have a suppressed viral load. To maximise the impact of ART, people living with HIV should be diagnosed early, initiated on ART and retained in ART care.  Engagement along the complete treatment cascade will determine the long-term success of the global response to HIV. 

This manuscript describes the trends in patient characteristics and outcomes over the first decade of scale-up of ART in Mozambique (2004-2013). During this period close to half a million people living with HIV were initiated on ART; six-month mortality declined from 7% to 2% but six-month loss to follow-up (LTFU) increased from 24% to 30%. The authors found that later calendar year of ART was associated with higher risk of LTFU; an increase in “silent” transfers (undocumented transfer between health facilities) might have contributed to this. There was an increasing female-to-male ratio over calendar period during the study, most likely due to scale-up of HIV testing during antenatal care and (since 2013) implementation of Option B+ (initiation of lifelong ART for all pregnant women). The authors conclude that increased enrolment among men is necessary to reduce the disproportionally high HIV-associated morbidity and mortality among men.  

Interestingly, this is the first study to report on nationwide outcomes of community ART support groups (CASG), and to quantify the effect of CASG on LTFU. Consistent with the recent systematic review by Nachega and colleagues (included in this issue of HIV This Month), the authors found no difference in mortality between patients who received their ART through CASG and patients who received their ART from facilities. Also consistent with this systematic review, CASG participation was associated with 35% lower LTFU rates. The authors therefore suggest ART distribution through CASG as a potential partial solution. Possible reasons for lower LTFU rates among CASG participants include reduced patient transport cost, reduced patient time at the clinic, increased patient accountability, and improved social support. However, the authors acknowledged that people agreeing to join a CASG might be people who would in any event be retained in care. CASG participants were more commonly unemployed and uneducated than non-participants, which might indicate that CASG participation is more attractive for patients with fewer financial resources.  

Men were less likely to participate in CASGs, emphasizing again the need for male-specific programmes. The authors advocate for further research, and suggest offering male-only CASG as a possible way to improve male participation in CASG.

Africa
Mozambique
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Evaluating strategies to improve HIV care outcomes

Evaluating strategies to improve HIV care outcomes in Kenya: a modelling study.

Olney JJ, Braitstein P, Eaton JW, Sang E, Nyambura M, Kimaiyo S, McRobie E, Hogan JW, Hallett TB. Lancet HIV. 2016 Dec;3(12):e592-e600. pii: S2352-3018(16)30120-5. doi: 10.1016/S2352-3018(16)30120-5. Epub 2016 Oct 19.

Background: With expanded access to antiretroviral therapy (ART) in sub-Saharan Africa, HIV mortality has decreased, yet life-years are still lost to AIDS. Strengthening of treatment programmes is a priority. We examined the state of an HIV care programme in Kenya and assessed interventions to improve the impact of ART programmes on population health.

Methods: We created an individual-based mathematical model to describe the HIV epidemic and the experiences of care among adults infected with HIV in Kenya. We calibrated the model to a longitudinal dataset from the Academic Model Providing Access To Healthcare (known as AMPATH) programme describing the routes into care, losses from care, and clinical outcomes. We simulated the cost and effect of interventions at different stages of HIV care, including improvements to diagnosis, linkage to care, retention and adherence of ART, immediate ART eligibility, and a universal test-and-treat strategy.

Findings: We estimate that, of people dying from AIDS between 2010 and 2030, most will have initiated treatment (61%), but many will never have been diagnosed (25%) or will have been diagnosed but never started ART (14%). Many interventions targeting a single stage of the health-care cascade were likely to be cost-effective, but any individual intervention averted only a small percentage of deaths because the effect is attenuated by other weaknesses in care. However, a combination of five interventions (including improved linkage, point-of-care CD4 testing, voluntary counselling and testing with point-of-care CD4, and outreach to improve retention in pre-ART care and on-ART) would have a much larger impact, averting 1.10 million disability-adjusted life-years (DALYs) and 25% of expected new infections and would probably be cost-effective (US$571 per DALY averted). This strategy would improve health more efficiently than a universal test-and-treat intervention if there were no accompanying improvements to care ($1760 per DALY averted).

Interpretation: When resources are limited, combinations of interventions to improve care should be prioritised over high-cost strategies such as universal test-and-treat strategy, especially if this is not accompanied by improvements to the care cascade. International guidance on ART should reflect alternative routes to programme strengthening and encourage country programmes to evaluate the costs and population-health impact in addition to the clinical benefits of immediate initiation.

Abstract  Full-text (free) access

Editor’s notes: Antiretroviral therapy has substantially reduced HIV-associated morbidity and mortality. However, maintaining a strong care cascade is challenging. A mathematical model for HIV transmission and care cascade was used to quantify the previous experience of people dying from HIV in a setting with an established antiretroviral therapy programme. The model was also used to simulate the cost and effect of HIV care programmes. The model was parameterised with data from HIV care programme in western Kenya supported by the Academic Model Providing Access To Healthcare. The model was analysed to assess: the impact of individual HIV programmes on the care cascade and the effect on outcomes of people living with HIV. These were compared with the baseline scenario without any programme. Disability-adjusted life-years (DALYs) averted, cost of care and HIV-associated deaths were used to quantify the effects of the programmes. The authors found that, strengthening each part of the care cascade through a combination of programmes could cost-effectively improve ART programmes. This is a very interesting study which suggest the need to prioritise HIV programmes to improve care in ART programmes over high-cost strategies.

Africa
Kenya
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Improving programmes: a thematic synthesis of qualitative studies of treatment adherence programmes

Barriers and facilitators of interventions for improving antiretroviral therapy adherence: a systematic review of global qualitative evidence.

Ma Q, Tso LS, Rich ZC, Hall BJ, Beanland R, Li H, Lackey M, Hu F, Cai W, Doherty M, Tucker JD. J Int AIDS Soc. 2016 Oct 17;19(1):21166. doi: 10.7448/IAS.19.1.21166. eCollection 2016.

Introduction: Qualitative research on antiretroviral therapy (ART) adherence interventions can provide a deeper understanding of intervention facilitators and barriers. This systematic review aims to synthesize qualitative evidence of interventions for improving ART adherence and to inform patient-centred policymaking.

Methods: We searched 19 databases to identify studies presenting primary qualitative data on the experiences, attitudes and acceptability of interventions to improve ART adherence among PLHIV and treatment providers. We used thematic synthesis to synthesize qualitative evidence and the CERQual (Confidence in the Evidence from Reviews of Qualitative Research) approach to assess the confidence of review findings.

Results: Of 2982 references identified, a total of 31 studies from 17 countries were included. Twelve studies were conducted in high-income countries, 13 in middle-income countries and six in low-income countries. Study populations focused on adults living with HIV (21 studies, n=1025), children living with HIV (two studies, n=46), adolescents living with HIV (four studies, n=70) and pregnant women living with HIV (one study, n=79). Twenty-three studies examined PLHIV perspectives and 13 studies examined healthcare provider perspectives. We identified six themes related to types of interventions, including task shifting, education, mobile phone text messaging, directly observed therapy, medical professional outreach and complex interventions. We also identified five cross-cutting themes, including strengthening social relationships, ensuring confidentiality, empowerment of PLHIV, compensation and integrating religious beliefs into interventions. Our qualitative evidence suggests that strengthening PLHIV social relationships, PLHIV empowerment and developing culturally appropriate interventions may facilitate adherence interventions. Our study indicates that potential barriers are inadequate training and compensation for lay health workers and inadvertent disclosure of serostatus by participating in the intervention.

Conclusions: Our study evaluated adherence interventions based on qualitative data from PLHIV and health providers. The study underlines the importance of incorporating social and cultural factors into the design and implementation of interventions. Further qualitative research is needed to evaluate ART adherence interventions.

Abstract  Full-text [free] access 

Editor’s notes: This is a review of studies using qualitative methods to explore the experiences of people living with HIV and healthcare providers involved in programmes to support antiretroviral treatment adherence. The thematic synthesis is presented in two ways. First, the reviewed studies are categorised by types of adherence programmes, such as task shifting, education, or directly observed therapy. Secondly, the authors present themes that are common across all reviewed studies. These include: the benefits and challenges of employing lay healthcare workers; the need to maintain confidentiality in adherence programmes; the benefits of supporting empowerment and social relationships for people living with HIV; and the need for culturally appropriate information and practice. Overall the review illustrates that adherence programmes can have more impact if they address confidentiality, strengthen social ties among people living with HIV and their communities; provide adequate compensation and training for lay healthcare workers; and sensitively reflect local social, cultural and religious norms and beliefs. 

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Voluntary male circumcision still a cost-effective intervention in the era of 90-90-90

Impact and cost of scaling up voluntary medical male circumcision for HIV prevention in the context of the new 90-90-90 HIV treatment targets.

Kripke K, Reed J, Hankins C, Smiley G, Laube C, Njeuhmeli E. PLoS One. 2016 Oct 26;11(10):e0155734. doi: 10.1371/journal.pone.0155734. eCollection 2016.

Background: The report of the Joint United Nations Programme on HIV/AIDS (UNAIDS) for World AIDS Day 2014 highlighted a Fast-Track Strategy that sets ambitious treatment and prevention targets to reduce global HIV incidence to manageable levels by 2020 and end the AIDS epidemic by 2030. The 90-90-90 treatment targets for 2020 call for 90% of people living with HIV to know their HIV status, 90% of people who know their status to receive treatment, and 90% of people on HIV treatment to be virally suppressed. This paper examines how scale-up of voluntary medical male circumcision (VMMC) services in four priority countries in sub-Saharan Africa could contribute to ending the AIDS epidemic by 2030 in the context of concerted efforts to close the treatment gap, and what the impact of VMMC scale-up would be if the 90-90-90 treatment targets were not completely met.

Methods: Using the Goals module of the Spectrum suite of models, this analysis modified ART (antiretroviral treatment) scale-up coverage from base scenarios to reflect the 90-90-90 treatment targets in four countries (Lesotho, Malawi, South Africa, and Uganda). In addition, a second scenario was created to reflect viral suppression levels of 75% instead of 90%, and a third scenario was created in which the 90-90-90 treatment targets are reached in women, with men reaching more moderate coverage levels. Regarding male circumcision (MC) coverage, the analysis examined both a scenario in which VMMCs were assumed to stop after 2015, and one in which MC coverage was scaled up to 90% by 2020 and maintained at 90% thereafter.

Results: Across all four countries, scaling up VMMC is projected to provide further HIV incidence reductions in addition to those achieved by reaching the 90-90-90 treatment targets. If viral suppression levels only reach 75%, scaling up VMMC leads to HIV incidence reduction to nearly the same levels as those achieved with 90-90-90 without VMMC scale-up. If only women reach the 90-90-90 targets, scaling up VMMC brings HIV incidence down to near the levels projected with 90-90-90 without VMMC scale-up. Regarding cost, scaling up VMMC increases the annual costs during the scale-up phase, but leads to lower annual costs after the MC coverage target is achieved.

Conclusions: The scenarios modeled in this paper show that the highly durable and effective male circumcision intervention increases epidemic impact levels over those of treatment-only strategies, including the case if universal levels of viral suppression in men and women are not achieved by 2020. In the context of 90-90-90, prioritizing continued successful scale-up of VMMC increases the possibility that future generations will be free not only of AIDS but also of HIV.

Abstract  Full-text [free] access 

Editor’s notes: Voluntary medical male circumcision (VMMC) has been shown to reduce the risk of female-to-male HIV transmission by up to 60%. It is a highly cost-effective HIV prevention activity. Since 2007, extensive efforts have been made to scale up VMMC in settings with high HIV prevalence and low levels of male circumcision, with the aim of reaching 80% VMMC coverage in 14 priority countries by 2016.  At the end of 2015, more than 11 million men in east and southern Africa had received VMMC.  In this modelling study, the authors look at the impact of scaling up VMMC to 90% coverage in four priority countries. The paper illustrates that VMMC scale-up can achieve additional reductions in HIV incidence above reductions achieved through testing and treatment alone. In the scenarios where the UNAIDS 90-90-90 treatment target is not completely met, VMMC scale-up can reduce HIV incidence to levels comparable to what would be achieved with the 90-90-90 treatment target. VMMC scale-up also resulted in lower long-term annual programme costs in all four settings. In 2015, UNAIDS set a target of an additional 27 million men in high-HIV prevalence settings receiving VMMC by 2021. Achieving this target will require new service delivery models, and innovative approaches to overcome current barriers that discourage men from accessing health care. VMMC is only one component in combination HIV prevention. It has advantages in being a single event that does not require ongoing adherence, offers men lifelong benefits, and is a valuable entry point for providing a broader range of health services to men including HIV testing. As this study demonstrates, VMMC remains a cost-effective strategy for reducing HIV incidence, even in the context of universal testing and treatment.  

Africa
Lesotho, Malawi, South Africa, Uganda
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A one-stop shop for HIV and non-communicable disease care in Kibera, Kenya

They just come, pick and go. The acceptability of integrated medication adherence clubs for HIV and non-communicable disease (NCD) patients in Kibera, Kenya.

Venables E, Edwards JK, Baert S, Etienne W, Khabala K, Bygrave H. AIDS Behav. 2016 Oct;20(10):2464-76. doi: 10.1007/s10461-016-1331-z.

Introduction: The number of people on antiretroviral therapy (ART) for the long-term management of HIV in low- and middle-income countries (LMICs) is continuing to increase, along with the prevalence of non-communicable diseases (NCDs). The need to provide large volumes of HIV patients with ART has led to significant adaptations in how medication is delivered, but access to NCD care remains limited in many contexts. Medication Adherence Clubs (MACs) were established in Kibera, Kenya to address the large numbers of patients requiring chronic HIV and/or NCD care. Stable NCD and HIV patients can now collect their chronic medication every three months through a club, rather than through individual clinic appointments.

Methodology: We conducted a qualitative research study to assess patient and health-care worker perceptions and experiences of MACs in the urban informal settlement of Kibera, Kenya. A total of 106 patients (with HIV and/or other NCDs) and health-care workers were purposively sampled and included in the study. Ten focus groups and 19 in-depth interviews were conducted and 15 sessions of participant observation were carried out at the clinic where the MACs took place. Thematic data analysis was conducted using NVivo software, and coding focussed on people's experiences of MACs, the challenges they faced and their perceptions about models of care for chronic conditions.

Results: MACs were considered acceptable to patients and health-care workers because they saved time, prevented unnecessary queues in the clinic and provided people with health education and group support whilst they collected their medication. Some patients and health-care workers felt that MACs reduced stigma for HIV positive patients by treating HIV as any other chronic condition. Staff and patients reported challenges recruiting patients into MACs, including patients not fully understanding the eligibility criteria for the clubs. There were also some practical challenges during the implementation of the clubs, but MACs have shown that it is possible to learn from ART provision and enable stable HIV and NCD patients to collect chronic medication together in a group.

Conclusions: Extending models of care previously only offered to HIV-positive cohorts to NCD patients can help to de-stigmatise HIV, allow for the efficient clinical management of co-morbidities and enable patients to benefit from peer support. Through MACs, we have demonstrated that an integrated approach to providing medication for chronic diseases including HIV can be implemented in resource-poor settings and could thus be rolled out in other similar contexts.

Abstract  Full-text [free] access 

Editor’s notes: As people living with HIV grow older, the chances of multi-morbidities increase. The number of non-communicable disease diagnosis is increasing generally in sub-Saharan Africa. This is not only because of changing lifestyles but also because of better diagnostic skills and ageing populations. The authors of this paper provide valuable information on how HIV and non-communicable disease care can be combined through the provision of ‘adherence clubs’. The clubs in Kibera, Kenya, have practical benefits for people living with more than one condition. The clubs also, as the authors state, provide a way to counter stigma around HIV, because the ‘medication adherence club’ is not disease specific. That said, a very useful and interesting finding from this research was the difference in views between health care workers and patients. The health care workers were often more positive in their views about the impact on stigma, for example, than the patients. It is apparent that sustained promotion of the purpose of the clubs is required. This publicity is necessary not only to spread information about the purpose of the club, but also to ensure people understand who is eligible to attend. If that publicity is successful, and the clubs can be sustained, the provision of an integrated service is an important step forward in chronic disease care models.

Africa
Kenya
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