Articles tagged as "Health care delivery"

Taking account of the human factor when introducing new technology – a cautionary tale

Unintended adverse consequences of electronic health record introduction to a mature universal HIV screening program.

Medford-Davis LN, Yang K, Pasalar S, Pillow MT, Miertschin NP, Peacock WF, Giordano TP, Hoxhaj S. AIDS Care. 2016 May;28(5):566-73. doi: 10.1080/09540121.2015.1127319. Epub 2016 Jan 5.

Early HIV detection and treatment decreases morbidity and mortality and reduces high-risk behaviors. Many Emergency Departments (EDs) have HIV screening programs as recommended by the Centers for Disease Control and Prevention. Recent federal legislation includes incentives for electronic health record (EHR) adoption. Our objective was to analyze the impact of conversion to EHR on a mature ED-based HIV screening program. A retrospective pre- and post-EHR implementation cohort study was conducted in a large urban, academic ED. Medical records were reviewed for HIV screening rates from August 2008 through October 2013. On 1 November 2010, a comprehensive EHR system was implemented throughout the hospital. Before EHR implementation, labs were requested by providers by paper orders with HIV-1/2 automatically pre-selected on every form. This universal ordering protocol was not duplicated in the new EHR; rather it required a provider to manually enter the order. Using a chi-squared test, we compared HIV testing in the 6 months before and after EHR implementation; 55 054 patients presented before, and 50 576 after EHR implementation. Age, sex, race, acuity of presenting condition, and HIV seropositivity rates were similar pre- and post-EHR, and there were no major patient or provider changes during this period. Average HIV testing rate was 37.7% of all ED patients pre-, and 22.3% post-EHR, a 41% decline (p < 0.0001), leading to 167 missed new diagnoses after EHR. The rate of HIV screening in the ED decreased after EHR implementation, and could have been improved with more thoughtful inclusion of existing human processes in its design.

Abstract access

Editor’s notes: The introduction of Electronic Health Records is beneficial for sharing patient information between health care providers in large health care settings. However, as the authors of this paper illustrate with this thoughtful case study, the introduction of electronic health records in some settings may worsen rather than improve care. In this case, the electronic health record system which was introduced did not faithfully mimic the manual system it replaced. HIV-screening which had previously been an ‘opt out’ option for laboratory testing, became an ‘opt-in’ option in the new system.  As a result, testing rates went down. Interestingly, a similar electronic system was introduced in another hospital nearby. The effect on testing rates was noticed there and a manual workaround put in place. The nursing director in that institution ‘was a very strong personal advocate and champion for the HIV screening programme there’.  The authors point to the importance of testing new systems carefully and checking for unintended consequences on patient care.

Northern America
United States of America
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Substantial morbidity despite preserved CD4 count in children with slow-progressing HIV

Chronic morbidity among older children and adolescents at diagnosis of HIV infection.

McHugh G, Rylance J, Mujuru H, Nathoo K, Chonzi P, Dauya E, Bandason T, Simms V, Kranzer K, Ferrand RA. J Acquir Immune Defic Syndr. 2016 May 11. [Epub ahead of print]. doi: 10.1097/QAI.0000000000001073

Background: Substantial numbers of children with HIV present to health care services in older childhood and adolescence, previously undiagnosed. These "slow-progressors" may experience considerable chronic ill-health, which is not well-characterised. We investigated the prevalence of chronic morbidity among children aged 6-15 years at diagnosis of HIV infection.

Methods: A cross sectional study was performed at seven primary care clinics in Harare, Zimbabwe. Children aged 6-15 years who tested HIV positive following provider-initiated HIV testing and counselling were recruited. A detailed clinical history and standardised clinical examination was undertaken. The association between chronic disease and CD4 count was investigated using multivariate logistic regression.

Results: Of the 385 participants recruited (52% female, median age 11 years (IQR 8-13)), 95% were perinatally HIV-infected. The median CD4 count was 375 (IQR 215-599) cells/mm3. Although 78% had previous contact with health care services, HIV testing had not been performed. There was a high burden of chronic morbidity: 23% were stunted, 21% had pubertal delay, 25% had chronic skin disease, 54% had a chronic cough of more than 1 month's duration, 28% had abnormal lung function and 12% reported hearing impairment. There was no association between CD4 count of <500cells/mm3 or <350 cells/mm3 with WHO stage or these chronic conditions.

Conclusion: In children with slow-progressing HIV, there is a substantial burden of chronic morbidity even when CD4 count is relatively preserved. Timely HIV testing and prompt ART initiation are urgently needed to prevent development of chronic complications.

Abstract  Full-text [free] access

Editor’s notes: Substantial numbers of infants who have perinatally acquired HIV are presenting with HIV infection in later childhood or adolescence. It is estimated that a third of infants living with HIV are ‘slow-progressors’ with a median survival of 16 years. This study found a large burden of chronic morbidity among older children and adolescent at the time of HIV diagnosis.   Interestingly, no association between CD4 count and WHO HIV disease stage was seen. Children with slow-progressing disease still appear go on to develop poor growth and chronic lung and skin disease despite preserved CD4 counts. Up until recently many of these children would not have been eligible to start ART based on the WHO 2013 HIV treatment guidelines. Recent changes to WHO guidelines recommending immediate ART for all, including older children, will hopefully reduce the risk of development of chronic complications in this population. Improved outcomes will only occur with timely diagnosis which requires increasing awareness of the burden of undiagnosed HIV disease, strengthening provider-initiated HIV testing and counselling and improving retention in ART care in this vulnerable age group.

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One-stop clinic-based ART initiation strengthens HIV treatment cascade

Initiating antiretroviral therapy for HIV at a patient's first clinic visit: the RapIT randomized controlled trial.

Rosen S, Maskew M, Fox MP, Nyoni C, Mongwenyana C, Malete G, Sanne I, Bokaba D, Sauls C, Rohr J, Long L. PLoS Med. 2016 May 10;13(5):e1002015. doi: 10.1371/journal.pmed.1002015. eCollection 2016.

Background: High rates of patient attrition from care between HIV testing and antiretroviral therapy (ART) initiation have been documented in sub-Saharan Africa, contributing to persistently low CD4 cell counts at treatment initiation. One reason for this is that starting ART in many countries is a lengthy and burdensome process, imposing long waits and multiple clinic visits on patients. We estimated the effect on uptake of ART and viral suppression of an accelerated initiation algorithm that allowed treatment-eligible patients to be dispensed their first supply of antiretroviral medications on the day of their first HIV-related clinic visit.

Methods and findings: RapIT (Rapid Initiation of Treatment) was an unblinded randomized controlled trial of single-visit ART initiation in two public sector clinics in South Africa, a primary health clinic (PHC) and a hospital-based HIV clinic. Adult (≥18 y old), non-pregnant patients receiving a positive HIV test or first treatment-eligible CD4 count were randomized to standard or rapid initiation. Patients in the rapid-initiation arm of the study ("rapid arm") received a point-of-care (POC) CD4 count if needed; those who were ART-eligible received a POC tuberculosis (TB) test if symptomatic, POC blood tests, physical exam, education, counseling, and antiretroviral (ARV) dispensing. Patients in the standard-initiation arm of the study ("standard arm") followed standard clinic procedures (three to five additional clinic visits over 2-4 wk prior to ARV dispensing). Follow up was by record review only. The primary outcome was viral suppression, defined as initiated, retained in care, and suppressed (≤400 copies/ml) within 10 mo of study enrollment. Secondary outcomes included initiation of ART ≤90 d of study enrollment, retention in care, time to ART initiation, patient-level predictors of primary outcomes, prevalence of TB symptoms, and the feasibility and acceptability of the intervention. A survival analysis was conducted comparing attrition from care after ART initiation between the groups among those who initiated within 90 d. Three hundred and seventy-seven patients were enrolled in the study between May 8, 2013 and August 29, 2014 (median CD4 count 210 cells/mm3). In the rapid arm, 119/187 patients (64%) initiated treatment and were virally suppressed at 10 mo, compared to 96/190 (51%) in the standard arm (relative risk [RR] 1.26 [1.05-1.50]). In the rapid arm 182/187 (97%) initiated ART ≤90 d, compared to 136/190 (72%) in the standard arm (RR 1.36, 95% confidence interval [CI], 1.24-1.49). Among 318 patients who did initiate ART within 90 d, the hazard of attrition within the first 10 mo did not differ between the treatment arms (hazard ratio [HR] 1.06; 95% CI 0.61-1.84). The study was limited by the small number of sites and small sample size, and the generalizability of the results to other settings and to non-research conditions is uncertain.

Conclusions: Offering single-visit ART initiation to adult patients in South Africa increased uptake of ART by 36% and viral suppression by 26%. This intervention should be considered for adoption in the public sector in Africa.

Abstract  Full-text [free] access 

Editor’s notes: This randomised controlled trial provides evidence that initiating ART at a single clinic visit limits pre-ART losses and increases the proportion in care with viral suppression within the first year of ART. Almost all people in the rapid arm initiated ART within 90 days. Attrition post-ART initiation remained quite high. One in three participants initiating ART in the rapid arm did not achieve the primary outcome of retention in care with viral suppression. However, this was not enough to offset the clear benefit of reduced pre-ART loss to follow-up.

There are a few things to note about the study. Firstly, the study design allowed for people who were enrolled at various stages in the pre-ART period, from HIV testing to receipt of CD4+ cell count. Fewer than half were enrolled on the day of HIV diagnosis. Secondly, the trial procedures relating to ART initiation were performed by research staff embedded in the health facilities. The one-stop ART initiation strategy was quite intensive, involving point-of-care testing for CD4+ cell count, TB, and routine pre-ART blood tests. This took over two hours for a single person, and more than four hours if TB testing was required. Lastly, the virologic suppression outcome was based on viral load measurement at any point between three and 12 months. It will therefore be particularly interesting to see longer-term data on virologic suppression and retention to see whether the effects were sustained.

The effectiveness and cost-effectiveness of this strategy should now be evaluated. The removal of CD4+ cell count eligibility criteria for ART might help to streamline the pre-initiation procedures, but additional effort might be required to make this process more efficient and suitable for implementation in routine care settings.  

South Africa
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Family-focused, integrated prevention of mother-to-child HIV transmission care packages: the way forward for Nigeria?

Integrated prevention of mother-to-child HIV transmission services, antiretroviral therapy initiation, and maternal and infant retention in care in rural north-central Nigeria: a cluster-randomised controlled trial.

Aliyu MH, Blevins M, Audet CM, Kalish M, Gebi UI, Onwujekwe O, Lindegren ML, Shepherd BE, Wester CW, Vermund SH. Lancet HIV. 2016 May;3(5):e202-11. doi: 10.1016/S2352-3018(16)00018-7. Epub 2016 Feb 24.

Background: Antiretroviral therapy (ART) and retention in care are essential for the prevention of mother-to-child HIV transmission (PMTCT). We aimed to assess the effect of a family-focused, integrated PMTCT care package.

Methods: In this parallel, cluster-randomised controlled trial, we pair-matched 12 primary and secondary level health-care facilities located in rural north-central Nigeria. Clinic pairs were randomly assigned to intervention or standard of care (control) by computer-generated sequence. HIV-infected women (and their infants) presenting for antenatal care or delivery were included if they had unknown HIV status at presentation (there was no age limit for the study, but the youngest participant was 16 years old); history of antiretroviral prophylaxis or treatment, but not receiving these at presentation; or known HIV status but had never received treatment. Standard of care included health information, opt-out HIV testing, infant feeding counselling, referral for CD4 cell counts and treatment, home-based services, antiretroviral prophylaxis, and early infant diagnosis. The intervention package added task shifting, point-of-care CD4 testing, integrated mother and infant service provision, and male partner and community engagement. The primary outcomes were the proportion of eligible women who initiated ART and the proportion of women and their infants retained in care at 6 weeks and 12 weeks post partum (assessed by generalised linear mixed effects model with random effects for matched clinic pairs). The trial is registered with, number NCT01805752.

Findings: Between April 1, 2013, and March 31, 2014, we enrolled 369 eligible women (172 intervention, 197 control), similar across groups for marital status, duration of HIV diagnosis, and distance to facility. Median CD4 count was 424 cells per µL (IQR 268-606) in the intervention group and 314 cells per µL (245-406) in the control group (p<0.0001). Of the 369 women included in the study, 363 (98%) had WHO clinical stage 1 disease, 364 (99%) had high functional status, and 353 (96%) delivered vaginally. Mothers in the intervention group were more likely to initiate ART (166 [97%] vs 77 [39%]; adjusted relative risk 3.3, 95% CI 1.4-7.8). Mother and infant pairs in the intervention group were more likely to be retained in care at 6 weeks (125 [83%] of 150 vs 15 [9%] of 170; adjusted relative risk 9.1, 5.2-15.9) and 12 weeks (112 [75%] of 150 vs 11 [7%] of 168 pairs; 10.3, 5.4-19.7) post partum.

Interpretation: This integrated, family-focused PMTCT service package improved maternal ART initiation and mother and infant retention in care. An effective approach to improve the quality of PMTCT service delivery will positively affect global goals for the elimination of mother-to-child HIV transmission.

Abstract access

Editor’s notes: Nigeria currently has the highest prevalence of mother-to-child HIV transmission in the world. This is predominantly due to the limited coverage and delivery of effective prevention of mother-to-child HIV transmission programmes. Reported barriers to the scale up of effective prevention programmes include a shortage of skilled health care workers, fragmented maternal and child health services and an absence of male participation in antenatal care. This parallel, cluster-randomised controlled study aimed to address these barriers. It explored the potential benefit of providing an innovative combination of prevention of mother-to-child HIV transmission programmes to pregnant women living with HIV in rural north-central Nigeria.

Standard care comprised of health information, opt-out HIV testing, infant feeding counselling, referral for CD4 cell counts and treatment, home-based services, antiretroviral prophylaxis, and early infant diagnosis. The design of the programme package took a family-focused approach. It also included integrated mother and infant service provision, male partner and community engagement, task shifting and point-of-care CD4 testing. The impact of this approach was positive. Women who were in the programme were more likely to initiate antiretroviral therapy and be retained in care at six weeks and twelve weeks post-partum. Of particular significance was a 74% reduction in incident HIV infection in infants born to women who were in the programme.

This study demonstrates an effective package but it is difficult to identify which specific components were the most beneficial. Nevertheless, the findings highlight Nigeria’s need to develop holistic packages of care if it is to achieve elimination of mother-to-child HIV transmission goals.

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Inequalities in access to health care for older people living with HIV in South Africa

Health expenditure and catastrophic spending among older adults living with HIV.

Negin J, Randell M, Raban MZ, Nyirenda M, Kalula S, Madurai L, Kowal P. Glob Public Health. 2016 Apr 30:1-15. [Epub ahead of print]

Introduction: The burden of HIV is increasing among adults aged over 50, who generally experience increased risk of comorbid illnesses and poorer financial protection. We compared patterns of health utilisation and expenditure among HIV-positive and HIV-negative adults over 50.

Methods: Data were drawn from the Study on global AGEing and adult health in South Africa with analysis focusing on individual and household-level data of 147 HIV-positive and 2725 HIV-negative respondents.

Results: HIV-positive respondents reported lower utilisation of private health-care facilities (11.8%) than HIV-negative respondents (25.0%) (p = .03) and generally had more negative attitudes towards health system responsiveness than HIV-negative counterparts. Less than 10% of HIV-positive and HIV-negative respondents experienced catastrophic health expenditure (CHE). Women (OR 1.8; p < .001) and respondents from rural settings (OR 2.9; p < .01) had higher odds of CHE than men or respondents in urban settings. Over half the respondents in both groups indicated that they had received free health care.

Conclusions: These findings suggest that although HIV-positive and HIV-negative older adults in South Africa are protected to some extent from CHE, inequalities still exist in access to and quality of care available at health-care services - which can inform South Africa's development of a national health insurance scheme.

Abstract access

Editor’s notes: The study provides a valuable overview of the health expenditures of HIV-positive and negative older people (50 years and older) in South Africa. It should be noted that the data used in this analysis are from 2007-2008. Therefore, it is likely that some things may have changed as anti-retroviral therapy has become more available. Perhaps some of the negative experiences reported by people living with HIV may have changed. However, it is likely that waiting times in clinics and concerns about drug-stockouts, may not have changed. Nearly a decade on, the number of people in need of HIV-associated care, and the resulting burden on the health service remain immense. The authors point to the valuable role of the social security system in reducing the financial impact of HIV, and mitigating catastrophic health expenditures. 

The authors have produced an important paper, highlighting some of the inequities in health care access. Many of these inequities are likely to have persisted. It would be invaluable to have a similar analysis of more recent data in order to chart progress. 

South Africa
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Antiretroviral choice may affect malaria outcomes in children

Antiretroviral choice for HIV impacts antimalarial exposure and treatment outcomes in Ugandan children.

Parikh S, Kajubi R, Huang L, Ssebuliba J, Kiconco S, Gao Q, Li F, Were M, Kakuru A, Achan J, Mwebaza N, Aweeka FT. Clin Infect Dis. 2016 May 3. pii: ciw291. [Epub ahead of print]

Background: The optimal treatment of malaria in HIV-infected children requires consideration of critical drug-drug interactions in co-infected children, as these may significantly impact drug exposure and clinical outcomes.

Methods: We conducted an intensive and sparse pharmacokinetic and pharmacodynamic study in Uganda of the most widely adopted artemisinin-based combination therapy, artemether-lumefantrine. HIV-infected children on three different first-line antiretroviral therapies (ART) were compared to HIV-uninfected children not on ART, all of whom required treatment for Plasmodium falciparum malaria. Pharmacokinetic sampling for artemether, dihydroartemisinin (DHA) and lumefantrine exposure was conducted through day 21, and associations between drug exposure and outcomes through day 42 were investigated.

Results: 145 and 225 children were included in the intensive and sparse pharmacokinetic analyses, respectively. Compared to no ART, efavirenz reduced exposure to all antimalarial components by 2.1 to 3.4-fold; lopinavir/ritonavir increased lumefantrine exposure by 2.1-fold; and nevirapine reduced artemether exposure only. Day 7 concentrations of lumefantrine were 10-fold lower in children on efavirenz versus lopinavir/ritonavir-based ART, changes that were associated with an approximately 4-fold higher odds of recurrent malaria by day 28 in those on efavirenz versus lopinavir/ritonavir-based ART.

Conclusions: The choice of ART in children living in a malaria-endemic region has highly significant impacts on the pharmacokinetics and pharmacodynamics of artemether-lumefantrine treatment. Efavirenz-based ART reduces all antimalarial components and is associated with the highest risk of recurrent malaria following treatment. For those on efavirenz, close clinical follow-up for recurrent malaria following artemether-lumefantrine treatment, along with the study of modified dosing regimens that provide higher exposure is warranted.

Abstract access

Editor’s notes: This study looks at the pharmacokinetic (PK) and clinical outcomes for artemether/lumefantrine therapy of falciparum malaria in Ugandan children aged 1-8 years living without HIV and with HIV on antiretroviral therapy (ART) regimes containing efavirenz, nevirapine or lopinavir. The stand-out result is that malaria outcomes were better in children who were taking lopinavir-based ART, without any significant drug adverse effects. 

The most commonly-used ART combinations have extensive interactions with other classes of drugs.  The effects of these interactions on clinical outcomes cannot always be accurately predicted from PK studies in healthy adults. This is especially so for sick children whose drug handling may be different. Large PK studies of unwell children are difficult to do, so this study is a rare gem. In fact the PK results are largely as expected. Exposure to artemether and its active metabolite are reduced by efavirenz and nevirapine; and exposure to lumefantrine is reduced by efavirenz and increased by lopinavir with ritonavir. Lumefantrine is the component of the combination malaria therapy with a longer effect and is intended to provide protection from recurrence.

The big question is, what is the impact of these PK differences on clinical outcomes? This is where it gets complicated. In total some 370 malaria episodes were studied. The authors illustrate that the efavirenz group had substantially higher malaria recurrence than the lopinavir group. The lopinavir group had the highest levels of lumefantrine. The efavirenz group had similar outcomes to the HIV-negative group, despite having lower levels of lumefantrine.

The recurrence rate in this study, in an area of intense malaria transmission, is dominated by early reinfection rather than recrudesence. The great majority of children taking ART were also taking co-trimoxazole, which provides protection against malaria infection, giving all children taking ART additional protection versus malaria compared to HIV-negative children. The difference between the efavirenz and lopinavir groups is likely to be due to lumefantrine levels. Higher levels of lumefantrine persist in combination with lopinavir / ritonavir – an effect that might also apply to other protease inhibitors. WHO guidelines recommend lopinavir/ritonavir as part of first-line ART for children under three years old. Whether this effect is large enough to influence ART choices in older children will depend on local circumstances, particularly the malaria transmission rate 

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Trial shows improvements to uptake of VMMC and linkage into HIV care but little effect on ART initiation

Uptake of antiretroviral therapy and male circumcision after community-based HIV testing and strategies for linkage to care versus standard clinic referral: a multisite, open-label, randomised controlled trial in South Africa and Uganda.

Barnabas RV, van Rooyen H, Tumwesigye E, Brantley J, Baeten JM, van Heerden A, Turyamureeba B, Joseph P, Krows M, Thomas KK, Schaafsma TT, Hughes JP, Celum C. Lancet HIV. 2016 May;3(5):e212-20. doi: 10.1016/S2352-3018(16)00020-5. Epub 2016 Mar 10.

Background: Male circumcision decreases HIV acquisition by 60%, and antiretroviral therapy (ART) almost eliminates HIV transmission from HIV-positive people who are virally suppressed; however, coverage of these interventions has lagged behind targets. We aimed to assess whether community-based HIV testing with counsellor support and point-of-care CD4 cell count testing would increase uptake of ART and male circumcision.

Methods: We did this multisite, open-label, randomised controlled trial in six research-naive communities in rural South Africa and Uganda. Eligible HIV-positive participants (aged ≥16 years) were randomly assigned (1:1:1) in a factorial design to receive lay counsellor clinic linkage facilitation, lay counsellor follow-up home visits, or standard-of-care clinic referral, and then (1:1) either point-of-care CD4 cell count testing or referral for CD4 testing. HIV-negative uncircumcised men (aged 16-49 years) who could receive secure mobile phone text messages were randomly assigned (1:1:1) to receive text message reminders, lay counsellor visits, or standard clinic referral. The study biostatistician generated the randomisation schedule via a computer-generated random number program with varying block sizes (multiples of six or three) stratified by country. Primary outcomes for HIV-positive people were obtaining a CD4 cell count, linkage to an HIV clinic, ART initiation, and viral suppression at 9 months, and for HIV-negative uncircumcised men were visiting a circumcision facility and uptake of male circumcision at 3 months. We assessed social harms as a safety outcome throughout the study. We did the primary analyses by intention to treat. This trial is registered with, number NCT02038582.

Findings: Between June 6, 2013, and March 11, 2015, 15 332 participants were tested. 2339 (15%) participants tested HIV positive, of whom 1325 (57%) were randomly assigned to receive lay counsellor clinic linkage facilitation (n=437), lay counsellor follow-up home visits (n=449), or standard clinic referral (n=439), and then point-of-care CD4 cell testing (n=206, n=220, and n=213, respectively) or referral for CD4 testing (n=231, n=229, and n=226, respectively). 12 993 (85%) participants tested HIV negative, of whom 750 (6%) uncircumcised men were randomly assigned to receive clinic referral (n=230), text message reminders (n=288), or lay counsellor follow-up visits (n=232). 1218 (93%) of 1303 HIV-positive participants were linked to care, but only 488 (37%) participants initiated ART. Overall, 635 (50%) of 1272 HIV-positive individuals achieved viral suppression at 9 months: 219 (52%) of 419 participants in the clinic facilitation group, 202 (47%) of 431 participants in the lay counsellor follow-up group, and 214 (51%) of 422 participants in the clinic referral group, with no significant differences between groups (p=0.668 for clinic facilitation and p=0.273 for lay counsellor follow-up vs clinic referral). 523 (72%) of 734 HIV-negative men visited a circumcision facility, with no difference between groups. 62 (28%) of 224 men were circumcised in the male circumcision clinic referral group compared with 137 (48%) of 284 men in the text message reminder group (relative risk 1.72, 95% CI 1.36-2.17; p<0.0001) and 106 (47%) of 226 men in the lay counsellor follow-up group (1.67, 1.29-2.14; p=0.0001). No cases of study-related social harm were reported, including probing about partnership separation, unintended disclosure, gender-based violence, and stigma.

Interpretation: All the community-based strategies achieved high rates of linkage of HIV-positive people to HIV clinics, roughly a third of whom initiated ART, and of those more than 80% were virally suppressed at 9 months. Uptake of male circumcision was almost two-times higher in men who received text message reminders or lay counsellor visits than in those who received standard-of-care clinic referral. Clinic barriers to ART initiation should be addressed in future strategies to increase the proportion of HIV-positive people accessing treatment and achieving viral suppression.

Abstract access

Editor’s notes: This study described a robust evaluation of approaches to enhance uptake of antiretroviral therapy (ART) and voluntary medical male circumcision (VMMC) following community-based approaches of HIV testing (home-based and mobile HIV testing). For HIV negative men, the close to 50% uptake of VMMC from the text message reminder approach is especially encouraging as it seems a low cost method for wider scale-up. The limitation however is that reliable and private access to a phone would be necessary. Nonetheless, with the increasing availability of mobile phones in Africa, this is a promising approach.

The findings for people living with HIV are more complex. There was remarkably high (93%) linkage into care in the study settings at nine months – even in the referral only arm. Unfortunately, this did not translate into high proportions initiating ART overall, 37%. The benefits from the approaches to enhance uptake of ART were also mixed. ART initiation was increased with lay-counsellor follow-up but not with clinic facilitation, even though the latter did illustrate benefits for linkage to care. Further, viral suppression at nine months was similar across the study arms. Point-of-care CD4-counts did not affect rates of linkage, ART initiation or viral suppression.

The findings from this comprehensive evaluation of approaches to enhance uptake of services remind us of the opportunity not only to actively promote VMMC for HIV-negative men as part of HIV-testing services, but also that both text messages and lay counsellor follow-up can increase uptake. The study also highlights that increasing linkage to care for people living with HIV does not necessarily translate into increasing uptake of treatment. The authors describe possible reasons for this and it seems that addressing health systems challenges within facilities and innovations around treatment delivery should be priorities.

Health care delivery
South Africa, Uganda
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Silent transfers result in underestimation of retention on ART

Retention in care and patient-reported reasons for undocumented transfer or stopping care among HIV-infected patients on antiretroviral therapy in eastern Africa: application of a sampling-based approach.

Geng EH, Odeny TA, Lyamuya R, Nakiwogga-Muwanga A, Diero L, Bwana M, Braitstein P, Somi G, Kambugu A, Bukusi E, Wenger M, Neilands TB, Glidden DV, Wools-Kaloustian K, Yiannoutsos C, Martin J, East Africa International Epidemiologic Databases to Evaluate AIDS (EA-IeDEA) Consortium. Clin Infect Dis. 2016 Apr 1;62(7):935-44. doi: 10.1093/cid/civ1004. Epub 2015 Dec 17.

Background: Improving the implementation of the global response to human immunodeficiency virus requires understanding retention after starting antiretroviral therapy (ART), but loss to follow-up undermines assessment of the magnitude of and reasons for stopping care.

Methods: We evaluated adults starting ART over 2.5 years in 14 clinics in Uganda, Tanzania, and Kenya. We traced a random sample of patients lost to follow-up and incorporated updated information in weighted competing risks estimates of retention. Reasons for nonreturn were surveyed.

Results: Among 18 081 patients, 3150 (18%) were lost to follow-up and 579 (18%) were traced. Of 497 (86%) with ascertained vital status, 340 (69%) were alive and, in 278 (82%) cases, updated care status was obtained. Among all patients initiating ART, weighted estimates incorporating tracing outcomes found that 2 years after ART, 69% were in care at their original clinic, 14% transferred (4% official and 10% unofficial), 6% were alive but out of care, 6% died in care (<60 days after last visit), and 6% died out of care (≥60 days after last visit). Among lost patients found in care elsewhere, structural barriers (eg, transportation) were most prevalent (65%), followed by clinic-based (eg, waiting times) (33%) and psychosocial (eg, stigma) (27%). Among patients not in care elsewhere, psychosocial barriers were most prevalent (76%), followed by structural (51%) and clinic based (15%).

Conclusions: Accounting for outcomes among those lost to follow-up yields a more informative assessment of retention. Structural barriers contribute most to silent transfers, whereas psychological and social barriers tend to result in longer-term care discontinuation.

Abstract access 

Editor’s notes: The authors explore outcomes by tracing a sample of people who were lost to follow-up from antiretroviral therapy (ART) clinics. They collected data on reasons provided by patients for undocumented transfer out, or stopping ART. The findings are important, both to be able to critically evaluate the success of ART programmes (and individual clinics) in retaining people in care, and to identify barriers to retention which may be amenable to change. Consistent with findings elsewhere, the most common outcome among “lost” ART clinic attendees was “silent” (unofficial) transfer to another clinic, which, in this three-country study, accounted for a 10% underestimation of retention in care over two years. This highlights the pressing need for improved electronic medical record systems with centralised identification, in order to be able to track individuals between facilities so that accurate retention data can be collated.

As ART programmes move towards universal immediate initiation, the rate of stopping care (or transferring) will likely increase. In this study, 22% of people who had stopped care gave “I felt well” as a reason. The need for programmes to respond to the structural, psychological and social barriers identified will become even more important. 

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SMS technology can decrease time to ART initiation in infants, Rwanda

TRACnet Internet and SMS technology improves time to antiretroviral therapy initiation among HIV-infected infants in Rwanda.

Kayumba K, Nsanzimana S, Binagwaho A, Mugwaneza P, Rusine J, Remera E, Koama JB, Ndahindwa V, Johnson P, Riedel DJ, Condo J. Pediatr Infect Dis J. 2016 Mar 30. [Epub ahead of print]

Background: Delays in testing HIV-exposed infants and obtaining results in resource-limited settings contribute to delays for initiating antiretroviral therapy (ART) in infants. To overcome this challenge, Rwanda expanded its national mobile and internet-based HIV/AIDS informatics system, called TRACnet, to include HIV PCR results in 2010. This study was performed to evaluate the impact of TRACnet technology on the time to delivery of test results and the subsequent initiation of ART in HIV-infected infants.

Methods: A retrospective cohort study was conducted on 380 infants who initiated ART in 190 health facilities in Rwanda from March 2010 to June 2013. Program data collected by the TRACnet system was extracted and analyzed.

Results: Since the introduction of TRACnet for processing PCR results, the time to receive results has significantly decreased from a median of 144 days [IQR 121-197] to 23 days [IQR 17-43]. The number of days between PCR sampling and health facility receipt of results decreased substantially from a median of 90 days [IQR 83-158] to 5 days [IQR 2-8]. After receiving PCR results at a health facility, it takes a median of 44 days [IQR 32-77] before ART initiation. Result turnaround time was significantly associated with time to initiating ART (P<0.001). An increased number of staff trained for HIV care and treatment was also significantly associated with decreased time to ART initiation (P=0.004).

Conclusions: The use of mobile technology for communication of HIV PCR results, coupled with well-trained and skilled personnel, can reduce delays in communicating results to providers. Such reductions may improve timely ART initiation in resource-limited settings.

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Editor’s notes: Early identification and prompt treatment of infants who have perinatally acquired HIV is critical to decrease HIV-associated mortality in children. Testing of HIV-exposed infants is an integral part of prevention of mother-to-child HIV transmission programmes, and is termed early infant diagnosis (EID). Despite the scale-up of prevention of mother-to-child HIV transmission programmes, delays in obtaining HIV test results and in initiating infants on ART remains a serious programmatic challenge. Delays occur at several stages, including transport of specimens to centralised laboratories, processing of specimens by laboratories, receipt of results by health facilities and delay in initiation of antiretroviral therapy (ART) once positive results are received by health providers. Delays of up to several months between HIV testing and receipt of results have been observed in many high-burden countries.

In this study conducted in Rwanda, a short message service (SMS) was incorporated into the existing national TRACnet system to speed delivery of HIV test results from the central laboratory to health facilities. This interactive system is used for reporting by health facilities, either through a mobile phone or via the internet, depending on availability. Notably, this was complemented by strengthening all the processes between HIV testing and initiation of ART. This included training of nurses at health facilities, and improving the sample transportation process and the laboratory procedures at the central laboratory. The time from sample collection to receipt of results decreased from a median of 144 days to 23 days. Importantly this was also associated with a reducing in time to ART initiation.   

This study illustrates how a relatively simple SMS technology can be used to address structural barriers. Mobile phones are widely used in resource-constrained settings, and can be used to enhance efficiency of delivery of both HIV and other health services, as illustrated by this innovative study. However, success will require investment in improvement of transportation and laboratory systems, and training of health care providers, not only to utilise such systems, but also to respond to results in a timely manner. Further, there are further challenges in getting people to return to clinics to get their results and starting treatment. Strategies for engaging people will also be required if the ultimate outcome of prompt treatment of infants is to be realised. 

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What works to link people living with HIV to care - a review

Facilitators and barriers in HIV linkage to care interventions: a qualitative evidence review.

Tso LS, Best J, Beanland R, Doherty M, Lackey M, Ma Q, Hall BJ, Yang B, Tucker JD. AIDS. 2016 Apr 6. [Epub ahead of print]

Objective: To synthesize qualitative evidence on linkage to care interventions for people living with HIV.

Design: Systematic literature review.

Methods: We searched nineteen databases for studies reporting qualitative evidence on linkage interventions. Data extraction and thematic analysis were used to synthesize findings. Quality was assessed using the CASP tool and certainty of evidence was evaluated using the CERQual approach.

Results: Twenty-five studies from eleven countries focused on adults (24 studies), adolescents (8 studies), and pregnant women (4 Facilitators included community-level factors (i.e. task-shifting, mobile outreach, integrated HIV and primary services, supportive cessation programs for substance users, active referrals, and dedicated case management teams) and individual-level factors (encouragement of peers/family and positive interactions with healthcare providers in transitioning into care). One key barrier for people living with HIV was perceived inability of providers to ensure confidentiality as part of linkage to care interventions. Providers reported difficulties navigating procedures across disparate facilities and having limited resources for linkage to care interventions.

Conclusions: Our findings extend the literature by highlighting the importance of task-shifting, mobile outreach, and integrated HIV and primary services. Both community and individual level factors may increase the feasibility and acceptability of HIV linkage to care interventions. These findings may inform policies to increase the reach of HIV services available in communities.

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Editor’s notes: As the authors of this paper observe, most evaluations of linkage to care programmes have focused on quantitative assessment. This useful paper provides a thorough overview of the findings from 25 studies which used qualitative methods for assessment. Linkage-to- care programmes feasible in different country settings were identified in this review.  The authors also highlight gaps, most notably a lack of information on linkage-to-care programmes for men. They also note the need for longitudinal assessments that look at changes over time.

This paper is a useful synthesis of findings. But it is also an excellent example of how to carry out a systematic review of qualitative research. The description of the qualitative meta-synthesis the authors performed adds additional value to this paper. 

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