Antiretroviral Treatment Clients Research Articles

Optimizing HIV case identification among children and understanding remaining gaps in pediatric HIV testing in Kinshasa, DRC

BackgroundIt is critical to identify children living with HIV and initiate lifesaving antiretroviral treatment (ART) early. The Pediatric Accelerated Case Finding Effort focused on contact elicitation and HIV testing of ART clients’ biological children. We describe HIV testing and seropositivity rates following the initiative and gaps along the index testing cascade to inform pediatric HIV case finding optimization.MethodsThis mixed-methods study involved collecting monthly data on index testing outcomes, including elicitation (identifying biological children < 15 years), HIV testing and linkage to treatment from March 2020 to July 2021 in 35 facilities in Kinshasa. Data were summarized and presented for the first month (as a baseline proxy) and the entire study period. Qualitative data were collected from 14 healthcare workers participating in in-depth interviews and 33 community health workers in four focus group discussions. Audio recordings were transcribed and translated from Lingala or French into English and coded using MAXQDA software. Data were thematically analyzed according pediatric case finding barriers and strategies.ResultsAt baseline (March 2020), among 3337 eligible female index clients, 1634 (49.0%) underwent elicitation to identify children with unknown HIV status. By July 2021, all eligible clients (n = 11,734) had contacts identified. Of the contacts, 9871/11,848 (83.3%) were HIV-tested. Of contacts tested, 662 (6.7%) were diagnosed as HIV-positive, with 535 (80.8%) age 5–14 years; 99.5% initiated treatment. Providers attributed gaps in HIV testing primarily to testing refusals for children due to non-disclosure among parents and logistical or financial obstacles to transportation for tracing. COVID-19 movement restrictions and exposure fears also limited provider interactions for testing. Provider-implemented strategies included transport reimbursement, extensive counseling and alternative approaches to child testing for parents in sero-discordant relationships.ConclusionsFollowing intensified efforts around pediatric case finding, we found a high HIV positivity yield of 6.7% among previously undiagnosed children, with 81% of them aged ≥5 years. While elicitation improved over time, contact tracing for HIV testing remained the largest gap, missing opportunities to reach 17% of undiagnosed children. Ensuring adequate resources for tracing and HIV testing and supporting disclosure among couples, while emphasizing elicitation of ART clients’ biological children can help to optimize pediatric case finding.

Changes in HIV treatment differentiated care uptake during the COVID-19 pandemic in Zambia: interrupted time series analysis.

IntroductionDifferentiated service delivery (DSD) models aim to improve the access of human immunodeficiency virus treatment on clients and reduce requirements for facility visits by extending dispensing intervals. With the advent of the COVID‐19 pandemic, minimising client contact with healthcare facilities and other clients, while maintaining treatment continuity and avoiding loss to care, has become more urgent, resulting in efforts to increase DSD uptake. We assessed the extent to which DSD coverage and antiretroviral treatment (ART) dispensing intervals have changed during the COVID‐19 pandemic in Zambia.MethodsWe used client data from Zambia's electronic medical record system (SmartCare) for 737 health facilities, representing about three‐fourths of all ART clients nationally. We compared the numbers and proportional distributions of clients enrolled in DSD models in the 6 months before and 6 months after the first case of COVID‐19 was diagnosed in Zambia in March 2020. Segmented linear regression was used to determine whether the outbreak of COVID‐19 in Zambia further accelerated the increase in DSD scale‐up.Results and discussionBetween September 2019 and August 2020, 181,317 clients aged 15 or older (81,520 and 99,797 from 1 September 2019 to 1 March 2020 and from 1 March to 31 August 2020, respectively) enrolled in DSD models in Zambia. Overall participation in all DSD models increased over the study period, but uptake varied by model. The rate of acceleration increased in the second period for home ART delivery (152%), ≤2‐month fast‐track (143%) and 3‐month MMD (139%). There was a significant reduction in the enrolment rates for 4‐ to 6‐month fast‐track (−28%) and “other“ models (−19%).ConclusionsParticipation in DSD models for stable ART clients in Zambia increased after the advent of COVID‐19, but dispensing intervals diminished. Eliminating obstacles to longer dispensing intervals, including those related to supply chain management, should be prioritized to achieve the expected benefits of DSD models and minimize COVID‐19 risk.

Community-based differentiated service delivery models incorporating multi-month dispensing of antiretroviral treatment for newly stable people living with HIV receiving single annual clinical visits: a pooled analysis of two cluster-randomized trials in southern Africa.

IntroductionDifferentiated service delivery (DSD) models for HIV treatment decrease health facility visit frequency and limit healthcare facility‐based exposure to severe acute respiratory syndrome coronavirus 2. However, two important evidence gaps include understanding DSD effectiveness amongst clients commencing DSD within 12 months of antiretroviral treatment (ART) initiation and amongst clients receiving only single annual clinical consultations. To investigate these, we pooled data from two cluster‐randomized trials investigating community‐based DSD in Zimbabwe and Lesotho.MethodsIndividual‐level participant data of newly stable adults enrolled between 6 and 12 months after ART initiation were pooled. Both trials (conducted between August 2017 and July 2019) had three arms: Standard‐of‐care three‐monthly ART provision at healthcare facilities (SoC, control); ART provided three‐monthly in community ART groups (CAGs) (3MC) and ART provided six‐monthly in either CAGs or at community‐distribution points (6MC). Clinical visits were three‐monthly in SoC and annually in intervention arms. The primary outcome was retention in care and secondary outcomes were viral suppression (VS) and number of unscheduled facility visits 12 months after enrolment. Individual‐level regression analyses were conducted by intention‐to‐treat specifying for clustering and adjusted for country.Results and DiscussionA total of 599 participants were included; 212 (35.4%), 128 (21.4%) and 259 (43.2%) in SoC, 3MC and 6MC, respectively. Few participants aged <25 years were included (n = 32). After 12 months, 198 (93.4%), 123 (96.1%) and 248 (95.8%) were retained in SoC, 3MC and 6MC, respectively. Retention in 3MC was superior versus SoC, adjusted risk difference (aRD) = 4.6% (95% CI: 0.7%−8.5%). Retention in 6MC was non‐inferior versus SoC, aRD = 1.7% (95% CI: −2.5%−5.9%) (prespecified non‐inferiority aRD margin −3.25%). VS was similar between arms, 99.3, 98.6 and 98.1% in SoC, 3MC and 6MC, respectively. Adjusted risk ratio's for VS were 0.98 (95% CI: 0.92−1.03) for 3MC versus SoC, and 0.98 (CI: 0.95−1.00) for 6MC versus SoC. Unscheduled clinic visits were not increased in intervention arms: incidence rate ratio = 0.53 (CI: 0.16−1.80) for 3MC versus SoC; and 0.82 (CI: 0.25−2.79) for 6MC versus SoC.ConclusionsCommunity‐based DSD incorporating three‐ and six‐monthly ART refills and single annual clinical visits were at least non‐inferior to standard facility‐based care amongst newly stable ART clients aged ≥25 years.ClinicalTrials.gov: NCT03238846 & NCT03438370

Retention in care and factors critical for effectively implementing antiretroviral adherence clubs in a rural district in South Africa.

IntroductionDifferentiated models of care that include referral of antiretroviral treatment (ART) clients to adherence clubs are an important strategy to help clinics manage increased number of clients living with HIV in resource‐constrained settings. This study reported on (i) clinical outcomes among ART clients attending community‐based adherence clubs and (ii) experiences of adherence clubs and perceptions of factors key to successful adherence club implementation among clients and healthcare workers.MethodsA retrospective cohort analysis of routine data and a descriptive analysis of data collected through self‐administered surveys completed by clients and healthcare workers were completed. Clients starting ART at the study clinic, between January 2014 and December 2015, were included in the cohort analysis and followed up until December 2016. The survey data were collected from August to September 2017. The primary outcome for the cohort analysis was a comparison of loss to follow‐up (LTFU) between clients staying in clinic care and those referred to adherence clubs. Survey data reported on client experiences of and healthcare worker perceptions of adherence club care.ResultsCohort analysis reported on 465 participants, median baseline CD4 count 374 (IQR: 234 to 532) cells/μl and median follow‐up time 20.7 (IQR 14.1 to 27.7) months. Overall, 202 (43.4%) participants were referred to an adherence club. LTFU was lower in those attending an adherence club (aHR =0.25, 95% CI: 0.11 to 0.56). This finding was confirmed on analysis restricted to those eligible for adherence club referral (aHR =0.28, 95% CI: 0.12 to 0.65). Factors highlighted as associated with successful adherence club implementation included: (i) referral of stable clients to the club, (ii) an ideal club size of ≥20 members, (iii) club services led by a counsellor (iv) using churches or community halls as venues (v) effective communication between all parties, and (vi) timely delivery of prepacked medication.ConclusionsThis study showed good clinical outcomes, positive patient experiences and healthcare worker perceptions of the adherence club model. Factors associated with successful adherence club implementation, highlighted in this study, can be used to guide implementers in the scale‐up of adherence club services across varied high‐burden settings.

Cultural Adaptation of 2 Evidence-Based Alcohol Interventions for Antiretroviral Treatment Clinic Patients in Vietnam.

In Vietnam where alcohol use is culturally normative and little treatment is available, persons living with HIV (PLWH) who consume alcohol at unhealthy levels are at greatly increased risk for negative health outcomes. We describe the first systematic adaptation of 2 evidence-based alcohol interventions for use in Vietnam: a combined motivational enhancement therapy/cognitive behavioral therapy and a brief alcohol intervention. Using the situated information, motivation and behavioral skills model, and systematic procedures for tailoring evidence-based treatments, we identified core intervention content to be preserved and key characteristics to be tailored for relevance to the clinical setting. We describe the use of in-depth interviews with antiretroviral treatment clients and providers, expert input, and counselor training procedures to develop tailored manuals for counselors and clients. Adapting evidence-based alcohol treatments for global settings is facilitated by the use of a model of behavior change and systematic procedures to operationalize the approach.

HIV stigma and associated factors among antiretroviral treatment clients in Jimma town, Southwest Ethiopia.

BackgroundHIV stigma has an important role in the spread of the AIDS epidemic. It profoundly affects the lives of individuals living with HIV/AIDS. Fear of being identified as having HIV may discourage a person from getting tested, accessing medical services, and obtaining medications. Thus, this study was aimed at assessing HIV-related stigma and associated factors among antiretroviral treatment (ART) clients in Jimma town, Oromia region, Southwest Ethiopia.MethodsA facility-based cross-sectional study was conducted from March 11 to April 26, 2015, in ART clinics in Jimma town. Consecutively identified sample was obtained from ART clients who voluntarily participated in the survey after signing written consent. A structured interviewer-administered questionnaire was used to collect the data. Multiple linear regressions were conducted to assess the factors associated with various stigma domains.ResultsOut of 349 clients requested, 318 (91.1%) respondents voluntarily participated in the study; among them, 204 (64.2%) respondents were females and the mean age of the respondents was 32.9 years. The mean score (and possible range) of experienced HIV stigma was 41.5±12.6 (20.0–86.7), internalized stigma was 50.5±16.4 (20–96.5), and perceived stigma was 56.2±19.2 (20–100).ConclusionThe study revealed that duration of ART use and provider-initiated and forced HIV testing were significantly associated with the three HIV stigma domains. Despite the lower experienced HIV stigma, there were higher internalized and perceived stigmas. Therefore, HIV counseling services should be strengthened for new ART beginners, including pretest counseling.

‘Fit to play’: Labour market behaviour in a cohort of public-sector antiretroviral treatment patients

ABSTRACTGiven the rapid scale-up of antiretroviral treatment (ART), it is necessary to explore the impact of ART on labour force participation, employment and labour productivity. This article investigates labour market outcomes in a prospective cohort of public-sector ART clients in the Free State province of South Africa. Empirical results suggest that labour force participation increased markedly as the proportion of those too ill to work declined, becoming indistinguishable from participation rates in the general population. Unemployment rates, however, remain above those reported for the general population. ART and its health-related benefits therefore translate into increases in labour force participation, but not employment. Employment status at HIV diagnosis strongly predicts absorption in the labour force. Public-sector ART clients should be referred to vocational rehabilitation and occupational therapy programmes, and to welfare-to-work programmes, and the unskilled to adult education and training and further education and training programmes.

Prospective Cohort Study of the Impact of Antiretroviral Therapy on Employment Outcomes Among HIV Clients in Uganda

This study evaluates the impact of antiretroviral treatment (ART) on employment-related outcomes using prospective, longitudinal analysis. Starting in January 2008, 602 treatment-naïve clients in one rural clinic and in one clinic in the capital Kampala were interviewed about their medical history, and psychosocial and socioeconomic adjustment at baseline and at months 6 and 12. Half of the sample was eligible to receive ART, while the other half was also in HIV care, but not yet eligible for ART, therefore providing a comparison group that is similar to the treatment group in that its members are HIV-positive and have made the decision to enroll in HIV care. We found improvements in general health, reduction in the incidence of pain and health interfering with work, as well as improvements in work-related self-efficacy for both groups over time, but significantly more so for the group receiving ART treatment. At baseline, less than half of the people in the ART group worked, but after 6 months more than three quarters of them were working, surpassing the fraction of people working in the control group after 1 year. Another key finding of the study was the importance of mental health as a key mediator for employment-related outcomes. These data indicate that ART clients experience greater improvements compared to pre-ART clients, and not only with regard to general health, but also in restoring confidence in their ability to work, as well as actual work status.

Socioeconomic status and barriers to the use of free antiretroviral treatment for HIV/AIDS in Enugu State, south-eastern Nigeria

With about 3 million people living with HIV, Nigeria has approximately 8% of the global burden of HIV cases. In 2009, only about 34% of those in need of antiretroviral treatment (ART) were able to access care, which means that Nigeria was far from achieving the United Nations target of ‘universal access’ by 2010. This study aimed to describe the barriers to accessibility and the coping strategies employed to overcome these barriers among users of free ART services overall and by socioeconomic status (SES). Data were collected from 240 people receiving ART at one urban and one peri-urban health facility in Enugu State, south-eastern Nigeria. Information on SES, demographic characteristics, and barriers and coping mechanisms for accessing ART were elicited from the respondents. The high cost of transportation, HIV stigma, and long waiting hours were found to be key barriers to the use of ART services. On average, ART clients spent just under four hours at the clinic during their monthly appointments. The use of personal savings and financial support from relatives were the main means to access treatment. When the data were analysed according to clients’ SES, transportation costs were a chief concern among the poorest while those who were better off were more likely to be concerned about stigma and discrimination. These findings should be borne in mind when designing and locating services to maximise ongoing accessibility to ART.

Migration, access to ART, and survivalist livelihood strategies in Johannesburg

Since the end of apartheid, patterns of migration into South Africa have shifted, and South Africa has become a destination for people from across the African continent and beyond — a small but important number of whom are refugees and asylum seekers. While South Africa has a protective, integrative, urban refugee policy, many of these individuals struggle to access the rights to which they are entitled, including healthcare. In addition, many lower-skilled international migrants are unable to legalise their stay in South Africa. As a result, international migrants often become part of the group of 'urban poor,' falling within the periphery of health and social welfare provision and relying on a survivalist livelihood within the informal economy. The health and wellbeing of an individual impact greatly on their ability to maintain a secure livelihood, and this becomes more difficult in the context of an HIV epidemic. This paper presents findings from a case study situated in the City of Johannesburg. The research made use of 1) 2006 survey data on migrant livelihood strategies in Johannesburg, 2) a study investigating non-citizens' access to antiretroviral treatment (ART) in the inner city, which included 3) a set of interviews conducted with migrant ART clients who were working in the city's informal economy. The findings indicate (a) the importance of the informal economy for migrants to Johannesburg; (b) the challenges that non-citizens face in accessing ART in the public sector in South Africa; and (c) the linkages between urban migrants' access to ART and their ability to maintain a survivalist livelihood. The paper argues that upholding people's right to ART for all who need it within South Africa will enable international migrants (including refugees and asylum seekers) to maintain an otherwise fragile survivalist livelihood, and this in turn will assist their self-reliance and integration into urban life. Recommendations are made to ensure that the right to healthcare is upheld for all in South Africa.