Articles tagged as "HIV testing"

Finding out at home: community members’ and healthcare workers’ views on the use of oral HIV self-testing in Kayelitsha, South Africa

'I know that I do have HIV but nobody saw me': oral HIV self-testing in an informal settlement in South Africa.

Martinez Perez G, Cox V, Ellman T, Moore A, Patten G, Shroufi A, Stinson K, Van Cutsem G, Ibeto M. PLoS One. 2016 Apr 4;11(4):e0152653. doi: 10.1371/journal.pone.0152653. eCollection 2016.

Reaching universal HIV-status awareness is crucial to ensure all HIV-infected patients access antiretroviral treatment (ART) and achieve virological suppression. Opportunities for HIV testing could be enhanced by offering self-testing in populations that fear stigma and discrimination when accessing conventional HIV Counselling and Testing (HCT) in health care facilities. This qualitative research aims to examine the feasibility and acceptability of unsupervised oral self-testing for home use in an informal settlement of South Africa. Eleven in-depth interviews, two couple interviews, and two focus group discussions were conducted with seven healthcare workers and thirteen community members. Thematic analysis was done concurrently with data collection. Acceptability to offer home self-testing was demonstrated in this research. Home self-testing might help this population overcome barriers to accepting HCT; this was particularly expressed in the male and youth groups. Nevertheless, pilot interventions must provide evidence of potential harm related to home self-testing, intensify efforts to offer quality counselling, and ensure linkage to HIV/ART-care following a positive self-test result.

 Abstract Full-text [free] access

Editor’s notes: This is a qualitative study with services users and healthcare workers from an HIV testing service ran by Médecins Sans Frontières (MSF) in Kayelitsha, South Africa. Couple and individual interviews and focus group discussions were conducted with 20 people. The participants discussed preferences of types of HIV testing and acceptability of HIV home-testing. The aim was to inform the pilot of an activity for the use of an oral HIV self-testing device (OraQuick). OraQuick is self-administered as an oral swab and gives results straightaway. The study sample included people who had previously refused an HIV test in the clinic, people who had received an HIV test in the clinic and agreed to a couple interview with their partners. Key reasons for refusing an HIV test in the clinic included: fear of finding out one’s status, fear of HIV-treated discrimination and concerns about confidentiality in testing services. Clinics were seen by male participants as ‘women’s places’.  Men thought visiting a service for an HIV test could harm one’s reputation. Home-testing was seen as preferable because it afforded more privacy. However, not wanting to know one’s status remains a barrier even with home-testing. There were concerns that partners (of both sexes) could pressure one another to test with OraQuick and tensions could arise in case of serodiscordant results. There were concerns that some users could get confused by a test that detects the presence of HIV in the mouth. This would contradict current awareness that HIV cannot be passed through kissing. False-negative tests could encourage unsafe sex. Participants worried that some people may not link into care and treatment after finding out they are HIV positive with a home-test. The study concludes that home-testing could reach populations (especially male partners of women living with HIV and young people) that do not come forward for testing through other services, including clinic-based and voluntary community testing. Many of the disadvantages of home-testing could be mitigated with appropriate education and pre-test counselling. The pilot study continues.  It is expected that the study will be able to address questions of linkage to care for people who test HIV-positive. 

Africa
South Africa
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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.

Abstract access  

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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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.

Abstract access  

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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Comparing the performance of different community-based measures of viral load as correlates for HIV incidence

Community viral load, antiretroviral therapy coverage, and HIV incidence in India: a cross-sectional, comparative study.

Solomon SS, Mehta SH, McFall AM, Srikrishnan AK, Saravanan S, Laeyendecker O, Balakrishnan P, Celentano DD, Solomon S, Lucas GM. Lancet HIV. 2016 Apr;3(4):e183-90. doi: 10.1016/S2352-3018(16)00019-9. Epub 2016 Mar 11.

Background: HIV incidence is the best measure of treatment-programme effectiveness, but its measurement is difficult and expensive. The concept of community viral load as a modifiable driver of new HIV infections has attracted substantial attention. We set out to compare several measures of community viral load and antiretroviral therapy (ART) coverage as correlates of HIV incidence in high-risk populations.

Methods: We analysed data from a sample of people who inject drugs and men who have sex with men, who were participants of the baseline assessment of a cluster-randomised trial in progress across 22 cities in India (ClinicalTrials.gov number NCT01686750). We recruited the study population by use of respondent-driven sampling and did the baseline assessment at 27 community-based sites (12 for men who have sex with men and 15 for people who inject drugs). We estimated HIV incidence with a multiassay algorithm and calculated five community-based measures of HIV control: mean log10 HIV RNA in participants with HIV in a community either engaged in care (in-care viral load), aware of their status but not necessarily in care (aware viral load), or all HIV-positive individuals whether they were aware, in care, or not (population viral load); participants with HIV in a community with HIV RNA more than 150 copies per mL (prevalence of viraemia); and the proportion of participants with HIV who self-reported ART use in the previous 30 days (population ART coverage). All participants were tested for HIV, with additional testing in HIV-positive individuals. We assessed correlations between the measures and HIV incidence with Spearman correlation coefficients and linear regression analysis.

Findings: Between Oct 1, 2012, and Dec 19, 2013, we recruited 26 503 participants, 12 022 men who have sex with men and 14 481 people who inject drugs. Median incidence of HIV was 0.87% (IQR 0.40-1.17) in men who have sex with men and 1.43% (0.60-4.00) in people who inject drugs. Prevalence of viraemia was more strongly correlated with HIV incidence (correlation 0.81, 95% CI 0.62-0.91; p<0.0001) than all other measures, although correlation was significant with aware viral load (0.59, 0.27-0.79; p=0.001), population viral load (0.51, 0.16-0.74; p=0.007), and population ART coverage (-0.54, -0.76 to -0.20; p=0.004). In-care viral load was not correlated with HIV incidence (0.29, -0.10 to 0.60; p=0.14). With regression analysis, we estimated that to reduce HIV incidence by 1 percentage point in a community, prevalence of viraemia would need to be reduced by 4.34%, and ART use in HIV-positive individuals would need to increase by 19.5%.

Interpretation: Prevalence of viraemia had the strongest correlation with HIV incidence in this sample and might be a useful measure of the effectiveness of a treatment programme.

Abstract access    

Editor’s notes: The ideal metric of impact for a programme looking at the prevention benefits of treatment would be the reduction in HIV incidence in the target population. Incidence is however very difficult to measure. ‘Community viral load’ has been proposed as an alternative. However its estimation using data collected either in a routine clinical setting or from a cohort study can suffer from bias, due to the population included not being representative of the wider population of people living with HIV.

This paper describes a study among gay men and other men who have sex with men and people who inject drugs carried out at 27 sites in India. Participants were recruited using respondent-driven sampling (in which respondents recruit their peers to produce a generally representative sample of hard-to-reach populations). At each site incidence was estimated using a multi-assay algorithm designed to identify seroconversion occurring approximately within the last six months. Five community-based measures of viral load were measured at each site. Of these, the prevalence of HIV viraemia (i.e. the proportion of the population with a viral load greater than 150 copies per mL), was most strongly associated with HIV incidence, while mean viral load among people in-care was not associated. This latter finding is important if a case-based surveillance approach using only data collected at clinics is to be used to estimate incidence. Population ART coverage, a measure of the proportion of the site participants on ART was also strongly correlated with incidence. As this can be measured through a simple questionnaire, rather than lab-based assays, it could be an easily and cheaply obtainable correlate for incidence, albeit one potentially prone to response bias.

Asia
India
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HIV genotyping to focus prevention efforts

Near real-time monitoring of HIV transmission hotspots from routine HIV genotyping: an implementation case study.

Poon AF, Gustafson R, Daly P, Zerr L, Demlow SE, Wong J, Woods CK, Hogg RS, Krajden M, Moore D, Kendall P, Montaner JS, Harrigan PR. Lancet HIV. 2016 May;3(5):e231-8. doi: 10.1016/S2352-3018(16)00046-1. Epub 2016 Apr 7.

Background: HIV evolves rapidly and therefore infections with similar genetic sequences are likely linked by recent transmission events. Clusters of related infections can represent subpopulations with high rates of transmission. We describe the implementation of an automated near real-time system to monitor and characterise HIV transmission hotspots in British Columbia, Canada.

Methods: In this implementation case study, we applied a monitoring system to the British Columbia drug treatment database, which holds more than 32 000 anonymised HIV genotypes for nearly 9000 residents of British Columbia living with HIV. On average, five to six new HIV genotypes are deposited in the database every day, which triggers an automated reanalysis of the entire database. We extracted clusters of five or more individuals with short phylogenetic distances between their respective HIV sequences. The system generated monthly reports of the growth and characteristics of clusters that were distributed to public health officers.

Findings: In June, 2014, the monitoring system detected the expansion of a cluster by 11 new cases during 3 months, including eight cases with transmitted drug resistance. This cluster generally comprised young men who have sex with men. The subsequent report precipitated an enhanced public health follow-up to ensure linkage to care and treatment initiation in the affected subpopulation. Of the nine cases associated with this follow-up, all had already been linked to care and five cases had started treatment. Subsequent to the follow-up, three additional cases started treatment and most cases achieved suppressed viral loads. During the next 12 months, we detected 12 new cases in this cluster with reduction in the onward transmission of drug resistance.

Interpretation: Our findings show the first application of an automated phylogenetic system monitoring a clinical database to detect a recent HIV outbreak and support the ensuing public health response. By making secondary use of routinely collected HIV genotypes, this approach is cost-effective, attains near real-time monitoring of new cases, and can be implemented in all settings in which HIV genotyping is the standard of care.

Abstract access

Editor’s notes: HIV genetic sequence data have been used retrospectively to characterise transmission patterns and association with risk factors. This is the first report of the use of such data in real-time to monitor transmission and inform a public health response.  Under current treatment guidelines in British Columbia, an HIV genotype test is routinely done on all individuals at the time of diagnosis.  The results are fed in to an automated monitoring system that can be used detect transmission ‘clusters’ and track their development. The case study demonstrates the value of this system in detecting an outbreak of transmitted drug resistance which was prioritised for public health programmes.  The authors acknowledge the ethical dilemmas associated with using HIV sequence data to inform public health actions. Accordingly, all individuals in the cluster were offered counselling, testing and treatment so as not to focus on any one person. One limitation of the monitoring system is that it relies on information from people who have presented for HIV testing, so people who are undiagnosed or not engaged with care are not represented. Although monitoring based on HIV sequence data is only possible in certain settings, it may provide a cost-effective tool for focused HIV prevention in situations where the data are already being collected as part of the standard care.

Northern America
Canada
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Combining community-based HIV testing methods to achieve high testing coverage

A hybrid mobile approach for population-wide HIV testing in rural east Africa: an observational study. 

Chamie G, Clark TD, Kabami J, Kadede K, Ssemmondo E, Steinfeld R, Lavoy G, Kwarisiima D, Sang N, Jain V, Thirumurthy H, Liegler T, Balzer LB, Petersen ML, Cohen CR, Bukusi EA, Kamya MR, Havlir DV, Charlebois ED. Lancet HIV. 2016 Mar;3(3):e111-9. doi: 10.1016/S2352-3018(15)00251-9. Epub 2016 Jan 26.

Background: Despite large investments in HIV testing, only an estimated 45% of HIV-infected people in sub-Saharan Africa know their HIV status. Optimum methods for maximising population-level testing remain unknown. We sought to show the effectiveness of a hybrid mobile HIV testing approach at achieving population-wide testing coverage.

Methods: We enumerated adult (≥15 years) residents of 32 communities in Uganda (n=20) and Kenya (n=12) using a door-to-door census. Stable residence was defined as living in the community for at least 6 months in the past year. In each community, we did 2 week multiple-disease community health campaigns (CHCs) that included HIV testing, counselling, and referral to care if HIV infected; people who did not participate in the CHCs were approached for home-based testing (HBT) for 1-2 months within the 1-6 months after the CHC. We measured population HIV testing coverage and predictors of testing via HBT rather than CHC and non-testing.

Findings: From April 2, 2013, to June 8, 2014, 168 772 adult residents were enumerated in the door-to-door census. HIV testing was achieved in 131 307 (89%) of 146 906 adults with stable residence. 13 043 of 136 033 (9.6%, 95% CI 9.4-9.8) adults with and without stable residence had HIV; median CD4 count was 514 cells per µL (IQR 355-703). Among 131 307 adults with stable residence tested, 56 106 (43%) reported no previous testing. Among 13 043 HIV-infected adults, 4932 (38%) were unaware of their status. Among 105 170 CHC attendees with stable residence 104 635 (99%) accepted HIV testing. Of 131 307 adults with stable residence tested, 104 635 (80%; range 60-93% across communities) tested via CHCs. In multivariable analyses of adults with stable residence, predictors of non-testing included being male (risk ratio [RR] 1.52, 95% CI 1.48-1.56), single marital status (1.70, 1.66-1.75), age 30-39 years (1.58, 1.52-1.65 vs 15-19 years), residence in Kenya (1.46, 1.41-1.50), and migration out of the community for at least 1 month in the past year (1.60, 1.53-1.68). Compared with unemployed people, testing for HIV was more common among farmers (RR 0.73, 95% CI 0.67-0.79) and students (0.73, 0.69-0.77); and compared with people with no education, testing was more common in those with primary education (0.84, 0.80-0.89).

Interpretation: A hybrid, mobile approach of multiple-disease CHCs followed by HBT allowed for flexibility at the community and individual level to help reach testing coverage goals. Men and mobile populations remain challenges for universal testing.

Abstract access

Editor’s notes: Achieving high levels of HIV testing coverage remains a challenge in many parts of sub-Saharan Africa. Conventional facility-based HIV testing models are insufficient to achieve the UNAIDS 90-90-90 targets and maximise the prevention benefits of treatment. This study was able to achieve extremely high levels of HIV testing coverage in a short period of time by strategically combining two community-based testing approaches. By offering testing through multiple-disease community health campaigns (CHC), followed by focused home-based testing (HBT) for individuals who did not attend the CHCs, nearly 90% of adult stable residents accepted HIV testing. This near-universal coverage was achieved in all 32 communities (range 84%‒95%) across two countries, in a variety of settings with different rates of HIV prevalence and of previous testing. Testing uptake in the CHCs varied considerably across the communities (52%‒82%), demonstrating the value of this hybrid approach to expand coverage. Non-stable residents, who were 13% of the population, had low rates of testing uptake (22%). High rates of mobility remain a particular challenge for universal HIV testing coverage, and additional strategies are necessary to engage this group. A potential limitation of a focused approach to HBT is the need for community enumeration.  Still the results illustrate that achieving high HIV testing coverage is feasible with a combination of community-based approaches.

Africa
Kenya, Uganda
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Kenya will have to scale, scale, scale to meet 90-90-90 targets

Progress in reversing the HIV epidemic through intensified access to antiretroviral therapy: results from a nationally representative population-based survey in Kenya, 2012.

Kim AA, Mukui I, N'Gan'ga L, Katana A, Koros D, Wamicwe J, De Cock KM, KAIS Study Group. PLoS One. 2016 Mar 1;11(3):e0148068. doi: 10.1371/journal.pone.0148068. eCollection 2016.

Background: In 2014, the Joint United Nations Programme on HIV/AIDS (UNAIDS) called for 90% of people living with HIV (PLHIV) to know their status, 90% of these to be on antiretroviral therapy (ART), and 90% of these to be virally suppressed by 2020 (90-90-90). It is not clear whether planned ART scale-up in countries whose eligibility criteria for ART initiation are based on recommendations from the 2013 World Health Organization treatment guidelines will be sufficient to meet UNAIDS' new global targets.

Materials and methods: Using data from a nationally representative population-based household survey of persons in Kenya we compared coverage and unmet need associated with HIV diagnosis, ART, and viral suppression among PLHIV aged 15-64 years in 2012 based on criteria outlined in the 2014 national ART guidelines and UNAIDS' 90-90-90 goals. Estimates were weighted to account for sampling probability and nonresponse.

Results: Eight in ten PLHIV aged 15-64 years needed ART based on treatment eligibility. Need for treatment based on the national treatment policy was 97.4% of treatment need based on UNAIDS' 90-90-90 goals, requiring an excess of 24 000 PLHIV to access treatment beyond those eligible for ART to achieve UNAIDS' 90-90-90 treatment target. The gap in treatment coverage was high, ranging from 43.1% nationally to 52.3% in Nyanza among treatment-eligible PLHIV and 44.6% nationally to 52.4% in Nyanza among all PLHIV.

Conclusion: Maintaining the current pace of ART scale-up in Kenya will result in thousands of PLHIV unreached, many with high viral load and at-risk of transmitting infection to others. Careful strategies for reaching 90-90-90 will be instrumental in determining whether intensified access to treatment can be achieved to reach all who require ART.

Abstract  Full-text [free] access 

Editor’s notes: The HIV field is pushing for aggressive scale-up of programmes to stem the HIV epidemic. In this regard, UNAIDS launched the 90-90-90 targets to motivate countries to increase awareness, testing and treatment of people living with HIV. This paper presents an analysis of data collected through the last national Kenya AIDS Indicator Survey (KAIS) which examines the number of people reached with testing and treatment in 2012 as compared with the 90-90-90 targets which the country adopted in 2014. The analysis illustrates that the scale up of testing and treatment will need to dramatically increase to meet the targets. The paper notes the importance of strategizing how best to reach the populations most affected. In Kenya’s case, a geographic approach to scaling up in higher incidence areas is now being implemented. Within the geographical approach, strategies include testing family members of people living with HIV, and community-based testing strategies (such as home-based testing and counselling and self-testing), delivered in settings with high HIV prevalence. Analyses such as the one presented in this paper can help other countries in similar situations to review how best to apply limited resources in order to meet targets. 

Africa
Kenya
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Fear of HIV test deters Ethiopians from getting malaria treatment

Concerns about covert HIV testing are associated with delayed presentation in Ethiopian adults with suspected malaria: a cross-sectional study.

Tadesse F, Deressa W, Fogarty AW. BMC Public Health. 2016 Feb 1;16(1):102. doi: 10.1186/s12889-016-2773-y

Background: Although early diagnosis and prompt treatment is important in preventing mortality from malaria, presentation of symptomatic individuals is often relatively late. One possible contributing factor is that fear of covert human immunodeficiency virus (HIV) testing delays presentation in adults. We aimed to survey the magnitude of such concerns and their association with delayed presentation with suspected malaria.

Methods: The study design was a health facility-based cross-sectional survey. The study population consisted of adults with suspected malaria who presented to health centres in central Ethiopia. Data were collected on attitudes to HIV testing and the duration between onset of symptoms and treatment seeking for suspected malaria.

Results: Eight hundred and ten individuals provided data. Of these, 406 (50 %) perceived that HIV testing was routinely done on blood donated for malaria diagnosis, and 327 (40 %) considered that community members delayed seeking medical advice because of these concerns. Concerns about HIV testing were associated with delays in attending for malaria diagnosis and treatment, with 117 individuals (29 %) of those with concerns about covert HIV testing waiting for 4 days or more, compared to 89 (22 %) of those who did not have any such concerns (p = 0.03). One hundred and twenty nine (16 %) individuals stated that concern about HIV testing was the main reason for the delay in seeking treatment, and 46 % of these individuals presented after experiencing symptoms of malaria infection for three days or more compared to 22 % of the 681 individuals who had no such concerns (p < 0.001). Analysis stratified by health centre demonstrated that these associations were a consequence of Meki health centre (odds ratio for duration of symptoms greater than 3 days if patient has concerns about HIV testing was 8.72; 95 % confidence intervals 3.63 to 20.97).

Conclusions: In adults living in central Ethiopia, the perception that HIV testing accompanied the investigation of suspected malaria was common. This is likely to impede presentation for early medical treatment in some areas and represents a reversible risk factor that deserves further study.

Abstract  Full-text [free] access 

Editor’s notes: This study addresses a relatively under-studied issue of concerns about HIV testing among adults with malaria. Previously, the authors of this paper found that about half of guardians of children with malaria symptoms in central Ethiopia thought the children’s blood samples were tested for HIV without consent. Guardians who believed this were more likely to delay bringing children for treatment. In this paper, the authors illustrate that the same is true for adults. In a representative survey of adults presenting with malaria symptoms at five health centres, about half of participants were concerned that their blood sample was secretly tested for HIV without their consent and about one in three thought that many or almost all members of their community believed this. Concern about covert HIV testing was associated with delayed presentation for management of suspected malaria overall, although this was largely due to the issue in one specific health centre. Electricity in the home, better education and urban versus rural home were not associated with this belief, although people in rural areas were more likely to delay treatment-seeking.

Beliefs about health care are culturally specific, so the results may not be generalizable to other contexts, but the belief that blood taken at health centres is secretly tested for HIV has been found in different cultural settings. Prompt treatment for suspected malaria is key and strategies to address these concerns are necessary. Possible strategies include investigations to clarify whether, in fact, blood is being tested for HIV without fully informed consent, and improved confidentiality of blood test results. 

Africa
Ethiopia
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Understanding barriers and facilitators to uptake and adherence of ART under Option B+ in Lilongwe, Malawi

Why did I stop? Barriers and facilitators to uptake and adherence to ART in option B+ HIV care in Lilongwe, Malawi.

Kim MH, Zhou A, Mazenga A, Ahmed S, Markham C, Zomba G, Simon K, Kazembe PN, Abrams EJ. PLoS One. 2016 Feb 22;11(2):e0149527. doi: 10.1371/journal.pone.0149527. eCollection 2016.

Causes for loss-to-follow-up, including early refusals of and stopping antiretroviral therapy (ART), in Malawi's Option B+ program are poorly understood. This study examines the main barriers and facilitators to uptake and adherence to ART under Option B+. In depth interviews were conducted with HIV-infected women who were pregnant or postpartum in Lilongwe, Malawi (N = 65). Study participants included women who refused ART initiation (N = 10), initiated ART and then stopped (N = 26), and those who initiated ART and remained on treatment (N = 29). The barriers to ART initiation were varied and included concerns about partner support, feeling healthy, and needing time to think. The main reasons for stopping ART included side effects and lack of partner support. A substantial number of women started ART after initially refusing or stopping ART. There were several facilitators for re-starting ART, including encouragement from community health workers, side effects subsiding, decline in health, change in partner, and fear of future sickness. Amongst those who remained on ART, desire to prevent transmission and improve health were the most influential facilitators. Reasons for refusing and stopping ART were varied. ART-related side effects and feeling healthy were common barriers to ART initiation and adherence. Providing consistent pre-ART counseling, early support for patients experiencing side effects, and targeted efforts to bring women who stop treatment back into care may improve long term health outcomes.

Abstract  Full-text [free] access 

Editor’s notes: Option B+ is a policy recommendation of World Health Organisation (WHO) that offers all pregnant and breast-feeding women living with HIV, life-long antiretroviral therapy (ART), regardless of CD4 count or clinical stage. Few studies have examined the challenges faced by pregnant and breast-feeding women, as they navigate the prevention of mother-to-child transmission cascade. The objective of this study was to identify the main barriers and facilitators to uptake and adherence to ART under Option B+ in Lilongwe, Malawi. This was done by conducting qualitative interviews (n=65) with women living with HIV who were pregnant or post-partum and had initiated ART, and women who refused or had stopped treatment.

The most important facilitator for initially starting and remaining on ART was the need to prevent transmission to their infants and to maintain health (prevent illness). Furthermore, ART was viewed as a solution to women’s health issues. This was especially the case when women believed that their health problems were associated with their HIV infection. There were a number of reasons that emerged for refusing ART. For most women the urgency of having to initiate ART under Option B+ was a major challenge. Women felt that they needed time, either to discuss their status with their partner or to accept their own status. In particular, the desire to speak to their partners emerged quite prominently reflecting a fear of disclosure and concern about their partner’s reaction. Another reason was generally feeling healthy before initiating treatment. Women wanted to wait until their health declined before initiating treatment. Religious beliefs did not play a significant role for most women. Only one woman refused because she believed that God, not healthcare providers, would tell her when she needed to start treatment. Side effects were the most commonly reported reason for stopping ART. Half of the 26 (N = 13) respondents who stopped ART did so because they experienced side effects, which included dizziness, nausea or vomiting, nightmares and hallucinations (9%). Women who had side effects also expressed challenges with food security. Side effects made some women question the efficacy of ART. The lack of partner support was another important barrier to ART adherence as women reported fear of disclosing their status to their husbands. Interestingly, although partner support was factored into women’s decision making, in most cases it was not the main consideration. The majority of partners (n=44) accepted their wives’ status, often sending reminders to take ART every night. However, many women did not return to the clinic even though their partners accepted their status (N = 17). One woman, for instance, took the money her husband gave her for transport to the clinic and spent it on other things. Forgetting to take pills or losing pills were other reasons given for lack of adherence. Stigma within the community was acknowledged as an issue, but there were few reports of overt discrimination. Further, even though some women refused or stopped ART, many of them re-started for reasons such as, feeling encouraged by a community health worker (CHW) or someone like a CHW. This was through their monthly home visits to check on women’s use of ART and to provide treatment support such as explaining the side-effects, counselling husbands and encouraging women to re-start. Decline in health, fear of future sickness, as well as reduction in side-effects were mentioned as reasons for re-starting on ART.

Overall, study authors mention that in the context of Option B+, inadequate time in preparing to initiate ART, as well as side effects emerged as more significant barriers as compared to previous studies on barriers and facilitators in non-Option B+ contexts. Economic barriers to care did not emerge as very significant in this study when comparted to other studies; however, a lack of food affects the severity of side effects. This suggests that economic barriers may manifest as an indirect mechanism that affects ART use. A strength of this study is the use of in-depth interviews with a range of women; not just women who stayed on ART, but also women who refused, stopped and re-started in the context of Option B+. Even though there might be overlap between the findings here and other qualitative research, particular barriers become more salient for women initiating ART in the context of Option B+. In prior assessments, women were only initiated on ART after being immunologically compromised, an assessment which often took longer than a month. This gave women time to reflect and accept their condition and communicate with their partner. In the case of Option B+ women felt they needed this time to prepare. The study demonstrates that challenges with uptake and adherence to ART remain. More time and support for women in decision-making, consistent pre-ART counselling, and support with side-effects may contribute to improvements in the long-run. As ART becomes increasingly normalised, some of these barriers may disappear.

Africa
Malawi
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HIV and injecting ‘krokodile’

Krokodile Injectors in Ukraine: fueling the HIV Epidemic?

Booth RE, Davis JM, Brewster JT, Lisovska O, Dvoryak S. AIDS Behav. 2016 Feb;20(2):369-76. doi: 10.1007/s10461-015-1008-z.

This study was designed to assess the characteristics of krokodile injectors, a recent phenomenon in Ukraine, and HIV-related risk factors among people who inject drugs (PWID). In three Ukraine cities, Odessa, Donetsk and Nikolayev, 550 PWID were recruited between December 2012 and October 2013 using modified targeted sampling methods. The sample averaged 31 years of age and they had been injecting for over 12 years. Overall, 39% tested positive for HIV, including 45% of krokodile injectors. In the past 30 days, 25% reported injecting krokodile. Those who injected krokodile injected more frequently (p < 0.001) and they injected more often with others (p = 0.005). Despite knowing their HIV status to be positive, krokodile users did not reduce their injection frequency, indeed, they injected as much as 85% (p = 0.016) more frequently than those who did not know their HIV status or thought they were negative. This behavior was not seen in non-krokodile using PWID. Although only a small sample of knowledgeable HIV positive krokodile users was available (N = 12), this suggests that krokodile users may disregard their HIV status more so than non-krokodile users. In spite of widespread knowledge of its harmful physical consequences, a growing number of PWID are turning to injecting krokodile in Ukraine. Given the recency of krokodile use in the country, the associated higher frequency of injecting, a propensity to inject more often with others, and what could be a unique level of disregard of HIV among krokodile users, HIV incidence could increase in future years.

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Editor’s notes: This is an important study among a highly vulnerable population of people who inject drugs where HIV prevalence has been consistently high over the last decade. This is one of the first empirical studies to examine the role of krokodile use on HIV risk acquisition. Krokodile is a home produced drug that has become more popular among people who inject drugs in Ukraine and the Russian Federation over the last five years. There is a long history of injection with home-produced opioids and amphetamines in these countries. The key component of krokodile is codeine, an opioid, but severe side effects have been associated with its injection including tissue damage, gangrene and organ failure. This study highlights some of the characteristics and HIV risk behaviours associated with krokodile injection to inform appropriate HIV prevention programming. Findings note that people who inject krokodile are more likely to inject with others. This reflects the home-produced nature of the drug that facilitates more group injecting as people congregate at places where it is produced to buy and inject. Programmes need to focus on strategies to avoid injecting with other people’s used injecting equipment, such as marking equipment, as can happen in group injecting scenarios. This programme would ensure there are sufficient numbers of clean needles/syringes in circulation. Worryingly, a higher prevalence of HIV was observed among people who inject krokodile, most likely associated with their older age and more frequent injecting. Targeted harm reduction information is urgently needed for krokodile users to prevent further HIV transmission and prevent soft tissue damage. There is already a large network of needle-syringe programmes and opioid substitution therapy available for people who inject drugs in Ukraine. However, access is often reduced since people who inject drugs are concerned about being arrested. Registration as a person who injects drugs causes problems with employment, families and police. Collaboration with the police is necessary to increase access to opioid substitution and needle and syringe programmes. Programmes are also required to reduce the stigma associated with injection in order to address the health needs of this population. 

Europe
Ukraine
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