Articles tagged as "Strengthen HIV integration"

High levels of unmet contraceptive needs among women living with HIV in Malawi

Pregnancy prevention and condom use practices among HIV-infected women on antiretroviral therapy seeking family planning in Lilongwe, Malawi.

Haddad LB, Feldacker C, Jamieson DJ, Tweya H, Cwiak C, Chaweza T, Mlundira L, Chiwoko J, Samala B, Kachale F, Bryant AG, Hosseinipour MC, Stuart GS, Hoffman I, Phiri S. PLoS One. 2015 Mar 26;10(3):e0121039. doi: 10.1371/journal.pone.0121039. eCollection 2015.

Background: Programs for integration of family planning into HIV care must recognize current practices and desires among clients to appropriately target and tailor interventions. We sought to evaluate fertility intentions, unintended pregnancy, contraceptive and condom use among a cohort of HIV-infected women seeking family planning services within an antiretroviral therapy (ART) clinic.

Methods: 200 women completed an interviewer-administered questionnaire during enrollment into a prospective contraceptive study at the Lighthouse Clinic, an HIV/ART clinic in Lilongwe, Malawi, between August and December 2010.

Results: Most women (95%) did not desire future pregnancy. Prior reported unintended pregnancy rates were high (69% unplanned and 61% unhappy with timing of last pregnancy). Condom use was inconsistent, even among couples with discordant HIV status, with lack of use often attributed to partner's refusal. Higher education, older age, lower parity and having an HIV negative partner were factors associated with consistent condom usage.

Discussion: High rates of unintended pregnancy among these women underscore the need for integrating family planning, sexually transmitted infection (STI) prevention, and HIV services. Contraceptive access and use, including condoms, must be improved with specific efforts to enlist partner support. Messages regarding the importance of condom usage in conjunction with more effective modern contraceptive methods for both infection and pregnancy prevention must continue to be reinforced over the course of ongoing ART treatment.

Abstract  Full-text [free] access

Editor’s notes: This paper highlights the high rate of unmet contraceptive need in sub-Saharan Africa. Almost all of the women living with HIV included in this study in Malawi reported that they did not desire future fertility. Most stated that their partners also did not desire more children.  Despite this, levels of consistent condom use were low. To ensure appropriate delivery of HIV and family planning services, it is important to understand the specific needs of women living with HIV. The study has a number of limitations, such as subjective retrospective reporting by the participants. However, the high rate of unintended pregnancies highlights the continued need to integrate family planning into HIV care. Despite the biases associated with self-reported condom use, the inconsistent condom use reported by women in this study emphasises the need for additional efforts to increase access to and uptake of effective contraceptive services to couples living with HIV, in addition to other HIV prevention and treatment services.

Africa
Malawi
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The impact of anti-retroviral treatment on home-based carers in Zambia

‘Deep down in their heart, they wish they could be given some incentives’: a qualitative study on the changing roles and relations of care among home-based caregivers in Zambia.

Cataldo F, Kielmann K, Kielmann T, Mburu G, Musheke M. BMC Health Serv Res. 2015 Jan 28;15(1):36. [Epub ahead of print]

Background: Across sub-Saharan Africa, the roll-out of antiretroviral treatment (ART) has contributed to shifting HIV care towards management of a chronic health condition. While the balance of professional and lay tasks in HIV care-giving has been significantly altered due to changing skills requirements and task-shifting initiatives, little attention has been given to the effects of these changes on health workers’ motivation and existing care relations.

Methods: This paper draws on a cross-sectional, qualitative study that explored changes in home-based care (HBC) in the light of widespread ART rollout in the Lusaka and Kabwe districts of Zambia. Methods included observation of HBC daily activities, key informant interviews with programme staff from three local HBC organisations (n = 17) and ART clinic staff (n = 8), as well as in-depth interviews with home-based caregivers (n = 48) and HBC clients (n = 31).

Results: Since the roll-out of ART, home-based caregivers spend less time on hands-on physical care and support in the household, and are increasingly involved in specialised tasks supporting their clients’ access and adherence to ART. Despite their pride in gaining technical care skills, caregivers lament their lack of formal recognition through training, remuneration or mobility within the health system. Care relations within homes have also been altered as caregivers’ newly acquired functions of monitoring their clients while on ART are met with some ambivalence. Caregivers are under pressure to meet clients and their families’ demands, although they are no longer able to provide material support formerly associated with donor funding for HBC.

Conclusions: As their responsibilities and working environments are rapidly evolving, caregivers’ motivations are changing. It is essential to identify and address the growing tensions between an idealized rhetoric of altruistic volunteerism in home-based care, and the realities of lay worker deployment in HIV care interventions that not only shift tasks, but transform social and professional relations in ways that may profoundly influence caregivers’ motivation and quality of care.

Abstract  Full-text [free] access

Editor’s notes: This paper fills an important gap. The authors examine the impact of the roll-out of antiretroviral treatment (ART) on home-based carers. Many papers have focused on recipients of ART and the effect on clinic services of providing ART. Little has been said about the impact of ART on home-based carers. Community health workers providing home-based care have been an important part of the support network for people living with HIV. It has been accepted that they provide the service as volunteers, and many have taken great pride in their work. The authors report a growing resentment at the lack of compensation for their work. Home-based carers have gained skills in supporting people on ART, acting as intermediaries between clinic and the person receiving care. Dwindling donor support for food and other items, provided to people living with HIV, has also affected home-based carers. They were often the ones who brought that aid to people living with HIV, and they are sometimes blamed for the loss. They may also be resented for checking up on ART adherence, affecting the trust between carer and the person living with HIV. This paper highlights the importance of looking at the unintended consequences of changes in healthcare delivery. A timely reminder that shifting treatment responsibilities away from the clinic is not without costs.        

Africa
Zambia
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HIV and disability – a stronger link than perhaps we thought?

When I was no longer able to see and walk, that is when I was affected most: experiences of disability in people living with HIV in South Africa.

Hanass-Hancock J, Myezwa H, Nixon SA, Gibbs A. Disabil Rehabil. 2014 Dec 19:1-11. [Epub ahead of print]

Abstract Purpose: HIV-related disability is an emerging issue in countries where HIV is endemic. This study aimed to understand experiences of disability in patients living with HIV in South Africa using the International Classification of Functioning, Disability and Health (ICF) as a guiding framework.

Methods: In-depth interviews were conducted with 19 HIV-positive people receiving ART through a public hospital in KwaZulu-Natal. Data were analyzed using collaborative qualitative content analysis.

Results: Participants described a variety of impairments related to mental, sensory, neuromusculoskeletal, skin, cardiovascular, digestive or reproductive systems. A tenuous relationship was evident between HIV and mental health impairments and the experience of other disabilities. Impairments affected participants' activity levels, especially mobility, domestic life, self-care and ability to work. Activity limitations affecting livelihood were often of more concern to participants than the impairments. Furthermore, women and men appeared to experience disability related to activities relevant to gendered norms in their cultural context.

Conclusions: More understanding of the intersections among HIV, disability, gender and livelihood is needed. To respond to the increased need to manage disability within HIV care in Africa, HIV programs should include rehabilitative approaches, address concerns related to livelihoods in households with disability and consider gender differences in the experience of disability.

Implications for Rehabilitation: HIV, its opportunistic infections and the treatments associated to them are related to health conditions and impairments that have the potential to develop into disability. Rehabilitation professionals in HIV endemic countries have therefore a larger and changing number of people living with HIV and need to consider the impact of the disease on the rehabilitation process. Mental health issues and disability might be interrelated and affect antiretroviral treatment (ART) adherence. Hence, rehabilitation has to use a holistic approach and integrate different therapy approaches (e.g. physiotherapy and mental health). The experience of living with HIV and developing disability has unreflected gender dynamics that need to be considered in rehabilitative care. Hence, the rehabilitation process has to consider the cultural realities and gendered experience of the condition. The study highlights the interrelationship between disability levels, the influence of environmental and social factors, and the changing experience related to gender. Hence, rehabilitation professionals in resource-poor settings have to go beyond the clinical response and therapy approaches in order to improve the activity and participation of people with disabilities and those living with HIV in their homes and communities. Community or home-based care might be avenues to further explore.

Abstract access 

Editor’s notes: While the existence of disability among people living with HIV and on antiretroviral therapy (ART) has been reported, few studies have investigated the individual’s experience of disability. This important study from South Africa aims to fill that gap. The authors used WHO International Classification of Functioning, Disability and Health (ICF) to guide their interviews and the analysis. They systematically sampled participants from an antiretroviral treatment clinic at a public hospital in KwaZulu-Natal. Importantly they did not purposely choose people with a visible disability because they wished to capture the perspectives of people who appeared to being doing well on ART as well as people who may have a visible impairment. No screening for disability was done prior to recruitment in the study. Ten of the 19 participants had no visible disability, but 17 out of 19 reported challenges at the impairment level of disability. These challenges were often related to mental function, sensory function and pain, headaches, painful feet and vision problems (which in some cases seemed to be linked to TB treatment). These different impairments affected mobility, social interactions, ability to make a living and self-esteem. Not all of these impairments were visible nor necessarily reported to clinic staff who perceived many of these people to be ‘doing well’ on ART.  The authors illustrate in this small but important study a great diversity of experience of disability across a small number of people in one clinic in South Africa. They highlight the importance of understanding the social and environmental factors which influence individual experience. Most importantly they stress the need to pay attention to impairment and the rehabilitation support that may be needed, even for people who appear to be doing well on medication.

Africa
South Africa
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Can community based health care form part of a wider primary health care strategy in sub-Saharan Africa?

Integration of community home based care programmes within national primary health care revitalisation strategies in Ethiopia, Malawi, South-Africa and Zambia: a comparative assessment.

Aantjes C, Quinlan T, Bunders J. Global Health. 2014 Dec 11;10(1):85. [Epub ahead of print]

Background: In 2008, the WHO facilitated the primary health care (PHC) revitalisation agenda. The purpose was to strengthen African health systems in order to address communicable and non-communicable diseases. Our aim was to assess the position of civil society-led community home based care programmes (CHBC), which serve the needs of patients with HIV, within this agenda. We examined how their roles and place in health systems evolved, and the prospects for these programmes in national policies and strategies to revitalise PHC, as new health care demands arise.

Methods: The study was conducted in Ethiopia, Malawi, South Africa and Zambia and used an historical, comparative research design. We used purposive sampling in the selection of countries and case studies of CHBC programmes. Qualitative methods included semi-structured interviews, focus group discussions, service observation and community mapping exercises. Quantitative methods included questionnaire surveys.

Results: The capacity of PHC services increased rapidly in the mid-to-late 2000s via CHBC programme facilitation of community mobilisation and participation in primary care services and the exceptional investments for HIV/AIDS. CHBC programmes diversified their services in response to the changing health and social care needs of patients on lifelong anti-retroviral therapy and there is a general trend to extend service delivery beyond HIV-infected patients. We observed similarities in the way the governments of South Africa, Malawi and Zambia are integrating CHBC programmes into PHC by making PHC facilities the focal point for management and state-paid community health workers responsible for the supervision of community-based activities. Contextual differences were found between Ethiopia, South Africa, Malawi and Zambia, whereby the policy direction of the latter two countries is to have in place structures and mechanisms that actively connect health and social welfare interventions from governmental and non-governmental actors.

Conclusions: Countries may differ in the means to integrate and co-ordinate government and civil society agencies but the net result is expanded PHC capacity. In a context of changing health care demands, CHBC programmes are a vital mechanism for the delivery of primary health and social welfare services.

Abstract  Full-text [free] access

Editor’s notes: This paper presents a comprehensive overview of the integration of community home based care (CHBC) with primary health care (PHC) strategies in four countries in sub-Saharan Africa. It emphasises the co-ordination of efforts between government and civil society. Using a multi method approach drawing on surveys, key informant interviews, focus group discussions and in-depth interviews the authors sought to gain an historical perspective on the changing form and content of CHBC and PHC in Ethiopia, Malawi, South Africa and Zambia. They focused on programmes that had been active for more than 10 years, were nationally representative and offered diversity of care. Their findings reveal a commitment to integration of care within PHC strategies in all the countries. This reflects the recent call by WHO to revitalise primary health care approaches in developing countries. The authors identified similarities across the countries, especially government commitment to revitalise PHC, a strong presence of actors providing CHBC, and the extension of focus beyond one disease such as HIV to the care and support for people with chronic conditions. They also identified three different approaches taken. These included supervision by the government (Malawi, Zambia), contracting (South Africa) and referral (Ethiopia). This reveals that approaches to integration need to be context-driven. This is a very useful paper to understand how HIV care is now being integrated into broader medical and social care and lessons learned from innovative HIV care are being applied more widely and in a more coordinated way.

Africa
Ethiopia, Malawi, South Africa, Zambia
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Why pregnant women and mothers living with HIV do not access, or do not stay in care

A systematic review of individual and contextual factors affecting ART initiation, adherence, and retention for HIV-infected pregnant and postpartum women.

Hodgson I, Plummer ML, Konopka SN, Colvin CJ, Jonas E, Albertini J, Amzel A, Fogg KP. PLoS One. 2014 Nov 5;9(11):e111421. doi: 10.1371/journal.pone.0111421. eCollection 2014.

Background: Despite progress reducing maternal mortality, HIV-related maternal deaths remain high, accounting, for example, for up to 24 percent of all pregnancy-related deaths in sub-Saharan Africa. Antiretroviral therapy (ART) is effective in improving outcomes among HIV-infected pregnant and postpartum women, yet rates of initiation, adherence, and retention remain low. This systematic literature review synthesized evidence about individual and contextual factors affecting ART use among HIV-infected pregnant and postpartum women.

Methods: Searches were conducted for studies addressing the population (HIV-infected pregnant and postpartum women), intervention (ART), and outcomes of interest (initiation, adherence, and retention). Quantitative and qualitative studies published in English since January 2008 were included. Individual and contextual enablers and barriers to ART use were extracted and organized thematically within a framework of individual, interpersonal, community, and structural categories.

Results: Thirty-four studies were included in the review. Individual-level factors included both those within and outside a woman's awareness and control (e.g., commitment to child's health or age). Individual-level barriers included poor understanding of HIV, ART, and prevention of mother-to-child transmission, and difficulty managing practical demands of ART. At an interpersonal level, disclosure to a spouse and spousal involvement in treatment were associated with improved initiation, adherence, and retention. Fear of negative consequences was a barrier to disclosure. At a community level, stigma was a major barrier. Key structural barriers and enablers were related to health system use and engagement, including access to services and health worker attitudes.

Conclusions: To be successful, programs seeking to expand access to and continued use of ART by integrating maternal health and HIV services must identify and address the relevant barriers and enablers in their own context that are described in this review. Further research on this population, including those who drop out of or never access health services, is needed to inform effective implementation.

Abstract Full-text [free] access

Editor’s notes: This systematic review is one of three by the same team, related to HIV and maternal mortality. The review findings illustrate that the individual and contextual factors which affect antiretroviral therapy (ART) initiation, adherence and retention for pregnant/postpartum women living with HIV are numerous. Fears over disclosure, and consequent stigma and discrimination feature in many of the studies reviewed. Practical barriers might be overcome, by making services more accessible. The lack of knowledge about HIV and treatment among some women may be addressed through information campaigns. However, the fear of negative consequences as a result of disclosure, even to health workers, presents significant barriers to care. This is something that is of particular note as Option B+ is rolled out. An important strength of this review is the combination of qualitative and quantitative studies. The meticulous description of the approach to the review is also welcome. The authors’ call for ‘consistent, standardised and appropriate measures of adherence and retention’ with a ‘longitudinal component’, is a valuable suggestion as the performance of countries in providing Option B+ begins to be compared.

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Integration of HIV testing into cervical cancer screening requires overcoming commodity supply challenges

Integrating HIV testing into cervical cancer screening in Tanzania: an analysis of routine service delivery statistics.

Plotkin M, Besana GV, Yuma S, Kim YM, Kulindwa Y, Kabole F, Lu E, Giattas MR. BMC Womens Health 2014 Sept 30: 14:120: doi:10.1186/1472-6874-14-120

Background: While the lifetime risk of developing cervical cancer (CaCx) and acquiring HIV is high for women in Tanzania, most women have not tested for HIV in the past year and most have never been screened for CaCx. Good management of both diseases, which have a synergistic relationship, requires integrated screening, prevention, and treatment services. The aim of this analysis is to assess the acceptability, feasibility and effectiveness of integrating HIV testing into CaCx prevention services in Tanzania, so as to inform scale-up strategies.

Methods: We analysed 2010-2013 service delivery data from 21 government health facilities in four regions of the country, to examine integration of HIV testing within newly introduced CaCx screening and treatment services, located in the reproductive and child health (RCH) section of the facility. Analysis included the proportion of clients offered and accepting the HIV test, reasons why testing was not offered or was declined, and HIV status of CaCx screening clients.

Results: A total of 24 966 women were screened for CaCx; of these, approximately one-quarter (26%) were referred in from HIV care and treatment clinics. Among the women of unknown HIV status (n = 18 539), 60% were offered an HIV test. The proportion of women offered an HIV test varied over time, but showed a trend of decline as the program expanded. Unavailability of HIV test kits at the facility was the most common reason for a CaCx screening client not to be offered an HIV test (71% of 6 321 cases). Almost all women offered (94%) accepted testing, and 5% of those tested (582 women) learned for the first time that they were HIV-positive.

Conclusion: Integrating HIV testing into CaCx screening services was highly acceptable to clients and was an effective means of reaching HIV-positive women who did not know their status; effectiveness was limited, however, by shortages of HIV test kits at facilities. Integration of HIV testing into CaCx screening services should be prioritized in HIV-endemic settings, but more work is needed to eliminate logistical barriers. The coverage of CaCx screening among HIV care and treatment-enrolled women in Tanzania may be low and should be examined.

Abstract  Full-text [free] access

Editor’s notes: This study discusses the integration of HIV testing into cervical cancer screening services in government health facilities in Tanzania, over a period of four years. The authors examined the acceptability (expressed as the acceptance of the HIV test by clients) and effectiveness (expressed as the number and proportion of women being offered an HIV test) of this approach.

Almost all women accepted testing, some 94%, but among the women of unknown HIV status only 60% were offered an HIV test. Insufficient supply of HIV test kits at health facilities together with a shortage of health care providers was the biggest challenge, limiting the effectiveness of the programme.

Due to their increased risk of cervical cancer, women in HIV care should be accessing screening services. However, data from this study suggested that integration in this direction was not as effective. The proportion of women in HIV care and treatment centres screened for cervical cancer varied between three percent and 46%. 

This study also demonstrates that data collected routinely as part of service delivery can be valuable for research purposes, especially when steps have been taken to strengthen the health information management system.

HIV testing
Africa
United Republic of Tanzania
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Bringing early infant HIV diagnosis to the clinic

Accurate early infant HIV diagnosis in primary health clinics using a point-of-care nucleic acid test.

Jani IV, Meggi B, Mabunda N, Vubil A, Sitoe NE, Tobaiwa O, Quevedo JI, Lehe JD, Loquiha O, Vojnov L, Peter TF. J Acquir Immune Defic Syndr. 2014 Sep 1;67(1):e1-4. doi: 10.1097/QAI.0000000000000250

Objective: To evaluate the accuracy of a point-of-care (POC) nucleic acid-based test (NAT) for early infant HIV diagnosis (EID) in primary health clinics in Mozambique.

Methods: POC and laboratory NAT EID tests were conducted on matched blood samples collected from 827 HIV-exposed infants younger than 18 months who were enrolled consecutively at 4 periurban primary health clinics and the central hospital in Maputo. Lancet heel draw blood collected by nurses was tested on site for HIV-1/-2 RNA on the Alere HIV NAT POC device and also used to create dried blood spots for later laboratory EID testing on the Roche Cobas Taqman/Ampliprep instrument. Results were used to determine the sensitivity, specificity, and agreement between the POC and laboratory NAT EID tests.

Results: The sensitivity and specificity of POC NAT EID testing were 98.5% (95% confidence interval (CI): 91.7 to 99.9, n = 65) and 99.9% (95% CI: 99.3 to 100, n = 762), respectively, compared with laboratory EID tests. Overall agreement was high (Cohen kappa = 0.981; 95% CI: 0.96 to 1.00). Positive (98.5%; 95% CI: 96.3 to 100) and negative 99.9% (95% CI: 99.7 to 100) test agreement was also high.

Conclusions: Primary health care nurses accurately performed POC NAT EID testing within primary health care clinics. On-site nucleic acid-based EID testing is technically feasible in clinic settings and could be used in efforts to improve access to pediatric HIV antiretroviral treatment.

Abstract access 

Editor’s notes: World Health Organization (WHO) recommends immediate antiretroviral therapy (ART) for all infants and young children. However, only about a third of children living with HIV in resource-limited settings receive ART, primarily because of lack of access to early infant HIV diagnosis.

Currently, early infant diagnosis requires a laboratory infrastructure and trained technicians, which are complex and costly. Therefore early infant diagnosis is often centralized, requiring transport of samples and a long turnaround time of up to several months for HIV test results to be returned. This has a severe impact on retention in care of infants and on timely ART initiation.       

This study compared the diagnostic accuracy of two tests. These included a point-of-care nucleic acid-based HIV test to that of a conventional laboratory-based test for early infant diagnosis. The tests were administered to exposed infants in primary health care clinics in Mozambique. A heel-prick blood sample was used to conduct the point-of-care tests, with results available on the same day. The point-of-care test had very high sensitivity and specificity compared to the laboratory test, with a 99.8% agreement between the two testing platforms. In addition, the point-of-care test was successfully performed on-site, by non-laboratory personnel, clinic nurses.

 Mothers of the infants enrolled in the study had mainly received single-dose nevirapine or WHO Option A regimen, for prevention of vertical transmission. The study did not compare the performance of the point-of-care test in infants at birth or assess its reliability in infants who might be exposed to higher levels of ART. Nevertheless, this study demonstrates the feasibility of using point-of-care testing for early infant HIV diagnosis in decentralised and rural health care settings. While this will require strengthening of health system elements, point-of-care assays are likely to significantly reduce delay in diagnosis and increase access to ART among HIV-positive infants. 

Africa
Mozambique
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Facing uncertainty – ageing with HIV

Aging with HIV: a model of disability.

Solomon P, O'Brien K, Wilkins S, Gervais N. J Int Assoc Provid AIDS Care. 2014 Aug 22. pii: 2325957414547431. [Epub ahead of print]

The purpose of this qualitative study was to develop a theoretical model describing the disability experienced by older adults living with HIV. Forty nine HIV positive men and women over the age of 50 years participated in in-depth qualitative interviews. Transcribed interviews were analyzed using grounded theory techniques. Uncertainty or worrying about the future was at the core of the model. Components of disability including symptoms and impairments, difficulties with day to day activities and challenges to social participation were experienced in the context of extrinsic or environmental factors (social support, stigma) and intrinsic contextual factors (positive living strategies, age). Time was an overarching component of the model. The model suggests areas for interventions to prevent or reduce disability related to the consequences of aging with HIV and improve overall quality of life.

 Abstract access 

Editor’s notes: This paper is a very welcome addition to the growing body of research on HIV and ageing. Time is highlighted in the findings. Time has been regained (because treatment has kept people alive to grow old) and time is moving too fast (as individuals fear accelerated ageing because of HIV). The authors also highlight the centrality of uncertainty in the lives of the 49 people interviewed. Uncertainty is central to ageing. No-one of us knows quite how well we may remain as we age. However, the interaction between HIV and the ageing process is an added layer of uncertainty. The average age of people in this study was only 56, so they were relatively young, older people. We can expect worries over adequate social support and managing increasing ill-health and disability, will increase as people age. The authors urge us to look at the impact of HIV on older people’s quality of life as a whole, in the design of programmes. This paper is a timely reminder of the social, mental and physical burden HIV continues to impose on people’s lives.

Northern America
Canada
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Improving linkage to pre-antiretroviral therapy care and antiretroviral therapy initiation

Interventions to improve or facilitate linkage to or retention in pre-ART (HIV) care and initiation of ART in low- and middle-income settings--a systematic review.

Govindasamy D, Meghij J, Kebede Negussi E, Clare Baggaley R, Ford N, Kranzer K. J Int AIDS Soc. 2014 Aug 1;17(1):19032. doi: 10.7448/IAS.17.1.19032. eCollection 2014.

Introduction: Several approaches have been taken to reduce pre-antiretroviral therapy (ART) losses between HIV testing and ART initiation in low- and middle-income countries, but a systematic assessment of the evidence has not yet been undertaken. The aim of this systematic review is to assess the potential for interventions to improve or facilitate linkage to or retention in pre-ART care and initiation of ART in low- and middle-income settings.

Methods: An electronic search was conducted on Medline, Embase, Global Health, Web of Science and conference databases to identify studies describing interventions aimed at improving linkage to or retention in pre-ART care or initiation of ART. Additional searches were conducted to identify on-going trials on this topic, and experts in the field were contacted. An assessment of the risk of bias was conducted. Interventions were categorized according to key domains in the existing literature.

Results: A total of 11 129 potentially relevant citations were identified, of which 24 were eligible for inclusion, with the majority (n=21) from sub-Saharan Africa. In addition, 15 on-going trials were identified. The most common interventions described under key domains included: health system interventions (i.e. integration in the setting of antenatal care); patient convenience and accessibility (i.e. point-of-care CD4 count (POC) testing with immediate results, home-based ART initiation); behaviour interventions and peer support (i.e. improved communication, patient referral and education) and incentives (i.e. food support). Several interventions showed favourable outcomes: integration of care and peer supporters increased enrolment into HIV care, medical incentives increased pre-ART retention, POC CD4 testing and food incentives increased completion of ART eligibility screening and ART initiation. Most studies focused on the general adult patient population or pregnant women. The majority of published studies were observational cohort studies, subject to an unclear risk of bias.

Conclusions: Findings suggest that streamlining services to minimize patient visits, providing adequate medical and peer support, and providing incentives may decrease attrition, but the quality of the current evidence base is low. Few studies have investigated combined interventions, or assessed the impact of interventions across the HIV cascade. Results from on-going trials investigating POC CD4 count testing, patient navigation, rapid ART initiation and mobile phone technology may fill the quality of evidence gap. Further high-quality studies on key population groups are required, with interventions informed by previously reported barriers to care.

 Abstract  Full-text [free] access 

Editor’s notes: To maximise the impact of antiretroviral therapy (ART), people living with HIV should be diagnosed as early as possible, after acquiring HIV infection. They should be enrolled and retained in pre-ART care, initiated on ART and retained in ART care. And at the same time ensuring long-term adherence to achieve and maintain viral load suppression.

This review focuses on the first few steps in the treatment cascade. The authors review the evidence for activities that enhance the linkage from HIV testing to pre-ART care, retain people in pre-ART care and enhance the linkage to ART initiation. Streamlining services to minimize patient visits, providing adequate medical and peer support, and providing incentives appear to decrease attrition between HIV testing and ART initiation. However, the authors point out that most of the included studies looked at the effect of a single activity on a single point, in the continuum of care. There is a gap in evidence of the effect of combined activities and programmes across the continuum of care.

With the clear trend towards the earliest possible initiation of ART, the pre-ART care period will become much shorter. However there will be need for activities to improve immediate linkage from a positive test result, to ART initiation and ART care.

Health care delivery
Africa, Asia
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Antiretroviral treatment outcomes - family matters!

A peer adherence support intervention to improve the antiretroviral treatment outcomes of HIV patients in South Africa: the moderating role of family dynamics.

Wouters E, Masquillier C, Ponnet K, le Roux Booysen F. Soc Sci Med. 2014 May 15;113C:145-153. doi: 10.1016/j.socscimed.2014.05.020. [Epub ahead of print]

Given the severe shortage of human resources in the healthcare sector in many countries with high HIV prevalence, community-based peer adherence support is being increasingly cited as an integral part of a sustainable antiretroviral treatment (ART) strategy. However, the available scientific evidence on this topic reports discrepant findings on the effectiveness of peer adherence support programmes. These conflicting findings to some extent can be attributed to the lack of attention to the social contexts in which peer adherence support programmes are implemented. This study explores the potential moderating role of family dynamics by assessing the differential impact of peer adherence support in different types of families, based on the theoretical underpinnings of the family functioning framework. These relationships were explored with the aid of multivariate statistical analysis of cross-sectional, post-trial data for a sample of 340 patients interviewed as part of the Effectiveness of Aids Treatment and Support in the Free State (FEATS) study conducted in the public-sector ART programme of the Free State Province of South Africa. The analysis reveals no significant overall differences in CD4 cell count between the intervention group accessing additional peer adherence support and the control group receiving standard care. When controlling for the potential moderating role of family dynamics, however, the outcomes clearly reveal a significant interaction effect between the adherence intervention and the level of family functioning with regard to treatment outcomes. Multi-group analysis demonstrates that peer adherence support has a positive effect on immunological restoration in well-functioning families, while having a negative effect in dysfunctional families. The study outcomes stress the need for peer adherence interventions that are sensitive to the suboptimal contexts in which they are often implemented. Generic, broad-based interventions do not necessarily facilitate the treatment adherence of the most vulnerable patient groups, particularly those without supportive family contexts. Tailoring interventions aimed at creating a health-enabling environment to the needs of these at-risk patients should therefore be a priority for both research and policy.

Abstract access 

Editor’s notes: Increasing numbers of people living with HIV now take antiretroviral therapy. Efforts to support life-long adherence to treatment have often focused on the individual by improving health centre and counselling support.  In this paper, Wouters and his colleagues look outside the health system, to the family setting. They show that the effectiveness of activities to support adherence, in this case peer support, can be both negatively and positively affected by the family context. A supportive family enhances the chances of peer adherence support working. Yet, for those accessing peer support without a supportive family, the treatment outcomes were worse than for similar individuals on standard care. This finding highlights a very important issue, that context matters. The most innovative and seemingly effective programme may fail if the home setting the person receiving treatment returns to is, in the words of the authors, ‘suboptimal’.  

Africa
South Africa
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