HIV Care Providers Research Articles

Burnout among HIV care providers: contextual understanding and measurements

Burnout among healthcare workers is a challenge for the availability and quality of healthcare services in many countries. Overall, burnout has far-reaching implications on doctors, patients, and the healthcare system. For example, emotionally and physically exhausted workers become less attentive and make mistakes more often. Moreover, contextual features of the healthcare system and the organizational culture of healthcare institutions can contribute to burnout prevention and vice versa. Burnout among healthcare workers also increases the risk of alcohol misuse, sleep disorders, fast food consumption, and the occurrence of obesity.Considering the shortage of standardized tools to measure burnout among medical workers, we aimed to adapt to the Ukrainian context one of the research tools: Maslach Burnout Inventory for Medical Personnel (MBI-HSS (MP)). The MBI-HSS (MP) addresses three scales: emotional exhaustion (EE) measures feelings of being emotionally overextended and exhausted by one’s work; depersonalization (DP) measures an unfeeling and impersonal response toward patients; personal accomplishment (PA) measures feelings of competence and achievement in one’s work.From November 2020 – April 2021 we conducted semi-structured interviews and questionnaires among HIV care providers (N = 117). The result revealed that 83.7 % of respondents had high emotional exhaustion, and 58.5 % had high depersonalization. But the dimension of personal achievement level was not indicative of burnout in this component: 45.5 % had a high level of personal achievement. Pre-test and piloting of the Ukrainian version of the Maslach Burnout Inventory for Medical Personnel (MBI-HSS (MP)) show the validity of this instrument. In addition, it was found that relationships with colleagues and the management of the healthcare institution were associated with higher rates of burnout among healthcare workers.

Barriers and Facilitators to Successful Intensive Adherence Counseling in Rural Northern Uganda: An Exploratory Interview with HIV-Positive Clients Using the COM-B Framework.

Intensive adherence counseling (IAC) was introduced as a strategy to enhance adherence to antiretroviral therapy (ART) among HIV clients with non-suppressed viral loads. There has been sub-optimal viral load suppression among HIV clients in Uganda enrolled in IAC. However, there is a scarcity of literature on the barriers and facilitators of successful IAC. We aim to explore the barriers and facilitators to successful IAC among HIV-positive clients seeking care in public health facilities in rural northern Uganda. This was an exploratory qualitative study conducted among 15 purposively sampled HIV-positive clients enrolled in IAC in public health facilities offering ART services in northern Uganda. We conducted in-depth interviews using semi-structured interview guides based on the capability, opportunity, motivation, and behavior (COM-B) framework for behaviour change. Data were analyzed using the deductive thematic approach of Braun and Clarke following the COM-B framework. The majority of the participants were females (60%), married (53%), and attained primary education (47%). Barriers to successful IAC were Capability - alcoholism and promiscuity, Opportunity - stigma and discrimination, delayed viral load result, shortage of food, and heavy workload; and Motivation - deteriorating health and lack of incentives. Facilitators to successful IAC were Capability - good knowledge of ART, good memory, and reminder alerts; Opportunity - availability of ART, social support, availability of ART, prolonged ART refill, and good counseling; and Motivation - desire to live longer and healthy and the desire to fulfill dreams and goals. Successful implementation of IAC needs to consider the context of the person in care thus the need to strengthen individualized IAC sessions. HIV care providers can adopt the COM-B framework to perform individualized IACs and use the information to strengthen the counseling sessions.

Health workers' knowledge and practice of Isoniazid preventive treatment guidelines in health facilities in Ebonyi State, Nigeria.

Isoniazid preventive therapy is recommended as part of a comprehensive HIV and AIDS care strategy. IPT is used as prophylaxis to reduce the incidence of TB in HIV-infected persons. However, its implementation has been very slow and has been influenced by several factors. This study assessed health workers' knowledge and adherence to Isoniazid Preventive Therapy guidelines. This was a cross-sectional study in six health facilities providing HIV care in Ebonyi State using a semi-structured, self-administered questionnaire. Data were collected from 85 health workers working in the HIV clinics. Data were also extracted from 200 patient treatment cards. Data analysis was carried out using SPSS version 20 software. Chi-square statistics and logistic regression were carried out to determine the association between socio-demographic characteristics and knowledge as well as self-reported practice of the guideline. Slightly over half of the respondents (58.8%) had good knowledge of the guideline, and the majority (75.3%) self-reported that they practiced the guideline. Only 17% of the treatment cards had isoniazid prescribed and only 11% of these had patient adherence assessed. The most common challenges to implementation of the guideline cited by health workers were unavailability of isoniazid, poor awareness, patient non-adherence, poor resources, high pill burden, and lack of training. Being a doctor and more than 3 years duration of work in the clinic were predictors of good knowledge. There was no predictor of practice. There was good knowledge and practice of the guideline from health worker self-reports, however, review of treatment card showed prescription was low. Further studies to explore and understand why there is such low prescription of INH/IPT to HIV patients despite good knowledge of healthcare professionals are recommended.

Black Men Who Have Sex with Men with HIV and Providers in HIV Care Settings Reflect on Stigma Reducing Strategies to Promote Engagement in Health Care.

Black men who have sex with men (BMSM) with HIV face significant challenges in accessing health care, including routine HIV care and behavioral health care due in part to perceived stigma in health care settings. This study examined the perspectives of BMSM with HIV and health care providers of how stigma experiences can affect health care access to both clinical and behavioral health support services. We explored how providers can mitigate stigma practices and improve health care experiences for BMSM with HIV, which may ultimately improve engagement in care. Working with eight sites as part of the BMSM Initiative, we recruited 20 BMSM with HIV and 13 health care providers to participate in individual virtual interviews. Participants were asked about perceived discrimination and stigma experienced by BMSM with HIV and strategies to reduce stigma experiences. Participants discussed how current practices could be improved to reduce stigma and how the use of telehealth promoted engagement in care. Recommended strategies to reduce stigma in HIV care delivery included offering personable communication, providing nonclinical resources along with standard HIV care, requiring staff diversity training, diversifying health care teams, and offering telehealth options. Employing stigma reduction strategies can create a safe and comfortable environment for BMSM with HIV to engage in behavioral care in HIV care settings. Providers should seek to incorporate these strategies into current and future models of care with the goal to improve overall health outcomes in BMSM with HIV.

A national audit of the management of HIV-2 in adults in the UK.

HIV-2 is rare in the UK. Many UK centres therefore only treat small numbers of people and there are few clinical trials to guide treatment. The British HIV Association (BHIVA) 2010 guidelines for management of HIV-2 formed the basis for this national audit, which aims to describe current practice and adherence to guidelines. All UK centres providing HIV care were contacted via the BHIVA "Members Matters" newsletter, and asked to submit anonymised, retrospective data for individuals living with HIV-2 accessing care at their service. Thirty-five sites responded and data were analysed for 167 individuals. Nearly half of individuals accessed care at one of four large London centres (77/167, 46%).Most people living with HIV-2 have taken antiretroviral therapy (ART) (132/167, 79%). The most common reasons for initiating treatment were clinical disease (34/89, 38%) and pregnancy (11/89, 12%). Most treatment-naïve individuals were initiated on a protease inhibitor based regimen (70/89, 79%). The use of integrase strand transfer inhibitor based regimens has increased over time.A significant minority of patients did not have baseline drug resistance testing performed, despite having a detectable viral load (15/52, 29%). Virological failure occurred in a minority of individuals (21/132, 16%); the most common drug regimen change in this context was the addition of an integrase strand transfer inhibitor (12/26 regimen changes, 46%). Most individuals living with HIV-2 were managed according to national guidance, with key areas for improvement including the choice of ART, drug resistance testing and the management of virological failure. It is hoped that this national audit, performed in conjunction with the updated 2021 BHIVA guidelines will improve the care of individuals living with HIV-2 in the UK.

Family APGAR and treatment outcomes among HIV patients at two ART Centres in Kumasi, Ghana.

This study aimed to examine the association between Family Adaptability, Partnership, Growth, Affection and Resolve (Family APGAR) and HIV treatment outcomes. A cross-sectional study using the Family APGAR questionnaire. The study was conducted in Kumasi, Ghana, at the Komfo Anokye Teaching Hospital and the Kwame Nkrumah University of Science and Technology Hospital. Consenting HIV-positive patients who had been on treatment for at least 12 months were recruited. The Family APGAR questionnaire was administered, and relevant data were extracted from hospital records and analysed using STATA® software. The relationship between Family APGAR and treatment outcomes was determined using Chi-squared tests or Fisher's exact test. Approximately 70.1% of 304 participants were females with a mean age of 41.8 years (±9.9). At treatment initiation, 47.4% of the patients presented at World Health Organisation (WHO) clinical stages I and II and had a CD4 count ≥ 200 cells/mm3. Females were less likely (Odds Ratio= 0.52; 95% CI=0.31 - 0.90, p = 0.018) to report late for treatment compared with the males. After 12 months of treatment, approximately 70% recorded undetectable viral load. Patients with functional families constituted 70.4%, which had a statistically significant relationship with viral load (p = 0.041). HIV care providers should incorporate family functionality evaluation into clinical practice and provide early essential support to enhance treatment outcomes. None declared.

Barriers and facilitators to scaling up Healthy Choices, a motivational interviewing intervention for youth living with HIV

BackgroundThis study included Community Health Workers and their supervisors from HIV clinical care teams who participated in the Healthy Choices intervention program. Healthy Choices is a Motivational Interviewing-based intervention aimed at improving medication adherence and reducing alcohol use for adolescents and emerging adults ages 16—24 living with HIV. In this study, the intervention was “scaled up” for delivery by local HIV care providers in real-world clinic settings.MethodsProviders (N = 21) completed semi-structured interviews (N = 29) about their experiences with intervention scale-up. Rigorous thematic analyses were conducted within discussions of barriers and facilitators of intervention implementation.ResultsThree dominant thematic areas emerged from the data: (1) perceptions of the Healthy Choices intervention, (2) engaging high risk YLH in in-person behavior interventions, and (3) perspectives on implementation of the intervention using local staff. Results offer insights into implementation of MI-based interventions for adolescents and emerging adults in clinic settings using local clinical staff instead of dedicated research staff.ConclusionsOverall, scaled-up intervention programs for youth are challenged to maintain scientific rigor, provide rigorous training and supports, and offer an attractive and engaging program.

Adaptation, acceptability and feasibility of Problem Management Plus (PM+) intervention to promote the mental health of young people living with HIV in Kenya: formative mixed-methods research.

Problem Management Plus (PM+) is a psychological intervention that seeks to address common mental disorders among individuals exposed to adversity. Thus far, the potential for delivering PM+ by mobile phones has not been evaluated. To adapt PM+ for telephone delivery (ten weekly sessions of about 45 min each) and preliminarily evaluate its acceptability and feasibility with young people living with HIV (YLWH) in coastal Kenya. This was a mixed-method formative research. Qualitative data collection included consultations with stakeholders, conducting key informant interviews with HIV care providers and focus group discussions with potential end-users, i.e. YLWH. Moreover, brief exit interviews with recipients of the adapted PM+ were conducted. Quantitative acceptability and feasibility indicators and outcome measures were tracked/assessed during PM+ preliminary implementation involving 70 YLWH. From the qualitative inquiries, the adapted PM+ emerged as contextually appropriate, acceptable and feasible for mobile phone delivery, despite some concerns around missing nonverbal cues and poor network connectivity. High recruitment (85%) and fair programme retention (69%) were observed. Intervention sessions over the telephone lasted 46 min on average (range 42-55 min). Preliminary feasibility data indicated that the adapted PM+ has the potential of reducing common mental disorders among YLWH from the Kenyan coast. PM+ is acceptable and can feasibly be delivered via mobile phone to YLWH in coastal Kenya. This study sets the stage for a future fully powered, randomised controlled trial assessing the efficacy of the adapted PM+ in this or a similar setting.

Preliminary report on the provision of HIV care to war refugees with HIV who are migrating from Ukraine: data from the ECEE Network Group.

The ECEE Network Group investigated early provision of HIV care to war refugees migrating from Ukraine in Central and Eastern Europe (CEE) through an online survey. Fourteen countries admitting war refugees from Ukraine on March 31, 2022, completed the survey. Most centers (86%) organized provision of same day antiretroviral therapy (ART) for at least 30 days (77%), but indicated that it may affect the local HIV care. CEE countries put effective emergency mechanisms, which need continuation with international support.

Evaluation of a training intervention to improve cancer care in Zimbabwe: Strategies to Improve Kaposi Sarcoma Outcomes (SIKO), a prospective community-based stepped-wedge cluster randomized trial.

IntroductionMost Zimbabweans access medical care through tiered health systems. In 2013, HIV care was decentralized to primary care clinics; while oncology care remained centralized. Most persons in Zimbabwe with Kaposi sarcoma (KS) are diagnosed late in their disease, and the prognosis is poor. Little is known about whether educational interventions could improve KS outcomes in these settings.MethodsInterventions to improve KS detection and management were evaluated at eight Zimbabwe primary care sites (four rural/four urban) that provided HIV care. Interventions included a standardized KS clinical evaluation tool, palliative care integration, standardized treatment and improved consultative services. Interventions were implemented between February 2013 and January 2016 using a randomized stepped‐wedge cluster design. Sites were monitored for KS diagnosis rates and KS outcomes, including early diagnosis (T0 vs. T1 tumour stage), participant retention and mortality. Analyses controlled for within‐clinic correlations.ResultsA total of 1102 persons with suspected KS (96% HIV positive) were enrolled: 47% incident (new diagnosis), 20% prevalent (previous diagnosis) and 33% determined as not KS. Early (T0) diagnosis increased post‐intervention, though not significant statistically (adjusted odds ratio [aOR] = 1.48 [95% confidence interval (95% CI): 0.66–3.79], p = 0.37). New KS diagnosis rates increased 103% (95% CI: 11–273%), p = 0.02) post‐intervention; although paired with an increased odds of incorrectly diagnosing KS (aOR = 2.08 [95% CI: 0.33–3.24], p = 0.001). Post‐intervention, non‐significant decreases in 90‐day return rates (adjusted hazard ratio [aHR] = 0.69 [95% CI: 0.38–1.45], p = 0.21) and survival (aHR = 1.36 [95% CI: 0.85–2.20], p = 0.20) were estimated.ConclusionsKS training interventions at urban and rural Zimbabwe decentralized primary care clinics significantly increased overall and incorrect KS diagnosis rates, but not early KS diagnosis rates, 90‐day return rates or survival.

Availability and experiences of differentiated antiretroviral therapy delivery at HIV care facilities in rural Zimbabwe: a mixed-method study.

IntroductionZimbabwe adopted differentiated HIV care policies in 2015 to promote client‐centred care and relieve strain on health facilities. We examined the availability, experiences and perceptions of differentiated antiretroviral therapy (ART) delivery in rural Zimbabwe following the policy adoption.MethodsWe undertook a cross‐sectional mixed methods study in all the 26 facilities providing HIV care in a rural district in Zimbabwe. We collected quantitative data about ART delivery and visit durations from 31 healthcare providers and a purposive stratified sample of 378 clients obtaining ART either through routine care or differentiated ART delivery models. We performed 26 semi‐structured interviews among healthcare providers and seven focus group discussions (FGDs) among clients to elicit their perceptions and experiences of ART delivery. Data were collected in 2019, with one follow‐up FGD in 2021. We analysed the transcripts thematically, with inductive coding, to identify emerging themes.ResultsTwenty facilities (77%) offered at least one differentiated ART delivery models, including community ART refill groups (CARGs; 13 facilities, 50%), fast‐track refill (8, 31%), family refill (6, 23%) or club refill (1, 4%). Thirteen facilities (50%) offered only one model. The median visit duration was 28 minutes (interquartile range [IQR]: 16–62). Participants in fast‐track had the shortest visit durations (18 minutes, IQR: 11–24). Confidentiality and disclosure of HIV status, travelling long distances, travel costs and waiting times were the main issues influencing clients’ views on differentiated ART delivery. Fast‐track refill was perceived as the preferred model of clients for its limited involuntary disclosure and efficiency. In contrast, group‐ and community‐based refill models reduced travel costs but were felt to be associated with involuntary disclosure of HIV status, which could discourage clients. Healthcare providers also experienced an additional workload when offering facility‐based group models, such as CARGs.ConclusionsDifferentiated ART delivery models were widely available in this rural setting, but most facilities did not offer a choice of models to address clients’ diverse preferences. A minority offered fast‐track refills, although this model was often mentioned as desirable. Confidentiality, travel expenses and client waiting times are key elements to consider when planning and rolling out differentiated HIV care.

Factors influencing the implementation of TB screening among PLHIV in selected HIV clinics in Ghana: a qualitative study

BackgroundDecreasing the burden of Tuberculosis (TB) among PLHIV through TB screening is an effective intervention recommended by the World Health Organization (WHO). However, after over a decade of implementation in Ghana, the intervention does not realize the expected outcomes. It is also not well understood whether this lack of success is due to implementation barriers. Our study, therefore, sought to examine the factors influencing the implementation of the intervention among people living with HIV (PLHIV) attending HIV clinics at district hospitals in Ghana.MethodsThis was a qualitative study conducted from 6th to 31 May 2019 in three regions of Ghana. We conducted 17 in-depth interviews (IDIs – comprising two regional, six districts and nine facility TB/HIV coordinators) and eight focus group discussions (FGD – consisting of a total of 65 participants) with HIV care providers. The Consolidated Framework for Implementation Research (CFIR) guided the design of interview guides, data collection and analysis. All responses were digitally audio-recorded and transcribed verbatim for coding and analysis using the Framework Approach. Participants consented to the interview and recording.ResultsThe main barriers to TB screening relate to the low commitment of the implementers to screen for TB and limited facility infrastructure for the screening activities. Facilitators of TB screening include (1) ease in TB screening, (2) good communication and referral channels, (3) effective goals and feedback mechanisms, (4) health workers recognizing the need for the intervention and (5) the role of chemical sellers.ConclusionsKey barriers and facilitators to the intervention are revealed. The study has shown that there is a need to increase HIV care providers and institutional commitment towards TB screening interventions. In addition, cost issues need to be assessed as they are drivers of sustainability. Our study also advances the field of implementation science through CFIR to better understand the factors influencing the implementation.

Provider perspectives on the use of motivational interviewing and problem-solving counseling paired with the point-of-care nucleic acid test for HIV care.

To evaluate provider perspectives on the use of a point-of-care nucleic acid test (POC NAT) and preferential opinions for motivational interviewing (MI) or problem-solving counseling (PSC) as an ultra-brief intervention for patients experiencing challenges to antiretroviral therapy (ART) adherence. A qualitative study was conducted among providers at an HIV care clinic in Seattle, Washington. Ten in-depth interviews with HIV care providers were completed, which explored determinants of acceptability, feasibility and preferences for a combined adherence counseling and POC NAT intervention for patients living with HIV. Interviews were analyzed through consensus coding and the Five A's Framework to inform thematic analysis. Providers favored the use of a combined adherence counseling technique and POC NAT for their non-adherent patients living with HIV. Providers believed the intervention was an improvement on current assessment and advising practices. However, concerns about extended wait times for the POC NAT results influenced perceptions about feasibility around clinic flow and incorporation into clinic practice. Providers believed that acceptability of POC NAT implementation would be enhanced by including a subset of patient populations whom tend to be in the clinic for longer periods, and in tandem face greater ART adherence challenges. The GAIN Study will be the first project to evaluate the implementation of POC NAT in the U.S. Continued formative work is ongoing and may illustrate how best to address feasibility and concern around the two-hour time to result. The planned GAIN study will incorporate some of the findings found in this qualitative study and pilot this intervention, including a time-in-motion analyses of clinic flow, which may help reduce perceived wide-scale adaptation of POC NAT and ART adherence counselling among PLHW. Future work, including a shorter time to results and/or lower limit detection could make a significant improvement in the provision of HIV care.

“Even if I’m undetectable, I just feel like I would die”: a qualitative study to understand the psychological and socioeconomic impacts of the COVID-19 pandemic on women living with HIV (WLWH) in Chicago, IL

BackgroundThe COVID-19 pandemic has affected the health and well-being of people worldwide, yet few studies have qualitatively examined its cumulative effects on ciswomen living with HIV (WLWH). We aimed to explore how the pandemic has impacted WLWH, including challenges related to HIV care, employment, finances, and childcare. We also investigated how HIV status and different psychosocial stressors affected their mental health.MethodsWe performed 25 semi-structured qualitative interviews with WLWH regarding the ways in which COVID-19 impacted their social determinants of health and physical well-being during the pandemic. 19 WLWH who received care at the University of Chicago Medicine (UCM) and 6 women who received care at Howard Brown Health, a federally qualified health center (FQHC) in Chicago, were interviewed remotely from June 2020 to April 2021. All interviews were audio recorded and transcribed. Interviews were thematically analyzed for commonalities regarding HIV-specific and general experiences of WLWH during the pandemic.ResultsThe majority of participants reported COVID-19 impacted their HIV care, such as appointment cancellations and difficulties adhering to antiretroviral therapy. In addition to HIV care obstacles, almost all participants described perceived heightened vulnerability to or fear of COVID-19. The pandemic also affected the socioeconomic well-being of participants, with reported financial strains and employment disruptions. Some mothers took on additional childcare responsibilities, such as homeschooling. Increased mental health concerns and negative psychological effects from the social isolation associated with the pandemic were also experienced by most participants.ConclusionsWe gained invaluable insight into how WLWH were challenged by and adapted to the COVID-19 pandemic, including its destabilizing effects on their HIV care and mental health. Women described how they undertook additional childcare responsibilities during the pandemic and how their HIV status compounded their concerns (e.g., perceived heightened vulnerability to COVID-19). Strategies to better support WLWH in maintaining their overall health throughout the pandemic include childcare assistance, access to affordable mental health services, support groups, and education from HIV care providers. These findings have significant implications for examining future health crises through the perspective of potential gender inequalities.

Factors associated with antiretroviral therapy adherence among adolescents living with HIV in the era of isoniazid preventive therapy as part of HIV care.

High levels of adherence to antiretroviral therapy (ART) are essential to promoting viral suppression and consequential good treatment outcomes. Adolescents living with HIV (ALHIV) in sub-Saharan Africa are less adherent to ART compared to adults, leading to lower rates of viral suppression and immunological recovery. We conducted a mixed-method study utilizing a convergent parallel approach to explore factors associated with ART adherence among ALHIV in the era of isoniazid preventive therapy (IPT) as part of HIV care. The quantitative data were collected from patient records from the period between 1 February 2017 and 31 January 2018 (6 months before and after IPT introduction), while qualitative data was collected from purposively selected patients and healthcare workers by in-depth interviews through a pretested interview guide. A total of 385 patient records (age 10-19 years) were analyzed in the two time periods, while 16 ALHIV (age 10-19 years) and three healthcare workers directly involved in adolescent care were interviewed. Quantitative data utilized logistic regression to measure the strength of association between IPT addition and ART adherence, whereas, qualitative data were analyzed using a thematic analysis approach. The mean age of participants in the quantitative section was 14.3 years (SD 2.7) and 178 were females, while the median age for adolescents interviewed was 14 (IQR 12-17) and 8 were females. Overall, we found an interaction of factors that influenced ART adherence. Added pill burden, on its own, did not affect ART adherence. Commonly reported factors that led to poor adherence were lack of status disclosure within the family, school pressure, and inadequate support from guardians and parents. According to retrospective patient records, complex ART regimens also worsened adherence (p = 0.0462). ART regimen was independently associated with adherence (OR 2.11 95% CI 0.97-4.53). Being on ART for a longer duration, enrolment into teen clubs, clinical psychosocial support, and self-reinforcement techniques were suggested to improve ART adherence. The interplay of multiple factors leads to poor rates of adherence. The introduction of IPT to ART packages may not independently affect ART adherence. Readily available psychosocial services and the presence of peer and guardian support is critical to optimal ART adherence. There is a need for ART centers that provide HIV care to adolescents to consider integrating psychosocial and other youth-friendly services into day-to-day clinic operations.

After-Crisis: Redundancies and Continuities in HIV-Related Skills, Knowledge, and Structures in Nairobi, Kenya

In the early 2000s, massive economic and technical resources accompanied the framing of HIV as a humanitarian and global health crisis in much of the Global South. These resources and framing combined to produce and enhance a wide range of HIV-related structures, skills, and knowledge with afterlives that have exceeded the crisis period in Kenya and elsewhere. Drawing on ethnographic fieldwork among HIV support groups in Nairobi, Kenya, conducted in the decade that followed the declared crisis period, we examine how local providers of HIV care and services understood the crisis and crisis narratives and practices. We highlight the consequences of after-crisis financial cutbacks, including anxiety, redundancy, financial hardship, and the devaluation and underutilization of expertise and care infrastructures. We argue that the structures, knowledge, and skills developed through engagements with international aid have complex afterlives, often concealed for lack of funding and forced dormancy. Our research examines strategies deployed by actors on the ground to continue offering services and support in the wake of crisis.

Fostering Resilient Health Systems in India: Providing Care for PLHIV Under the Shadow of COVID-19.

IntroductionThe novel coronavirus or COVID-19 has resulted in major human casualties, and extreme socio-economic crises causing catastrophic disturbances to health systems and communities alike. This study qualitatively explores the challenges experienced by healthcare providers while providing services to people living with HIV (PLHIV) during the pandemic outbreak and subsequent lockdown in India. The paper also explores strategies developed and adopted to provide continued care for PLHIV.MethodsUsing an empirical phenomenological approach, qualitative in-depth telephonic interviews were conducted with 19 HIV care providers from five states in India. The recorded interviews were transcribed and analyzed using inductive thematic analysis with the help of Dedoose software.ResultsFrom the analysis of participants' narratives, three main themes emerged: (1) Challenges of working during a pandemic; (2) Remodeling care delivery to ensure continuity of services; (3) Resilience.DiscussionOur findings highlight the challenges that providers faced, despite which, adaptive efforts were made to continue providing quality care for PLHIV through ingenious and innovative strategies. To foster resilient health systems, health workers are the primary stakeholders. We recommend formal social protection, comprehensive primary healthcare support, and sufficient capacity building for health workers for their self-care and pandemic preparedness.

Rapid Antiretroviral Therapy Program: Development and Evaluation at a Veterans Affairs Medical Center in the Southern United States.

Early HIV viral suppression (VS) improves individual health outcomes and decreases onward transmission. We designed an outpatient clinic protocol to rapidly initiate antiretroviral therapy (ART) in a large Veterans Health Administration (VA) HIV clinic. A pre-post evaluation was performed using a retrospective cohort study design for new diagnoses of HIV infection from January 2012 to February 2020. Time-to-event analyses were performed using the Cox proportional hazards model with the intervention group as the main exposure adjusted for integrase inhibitor usage, baseline viral load, age, gender, and race. Most of the patients were men (historical control: 94.8%, n = 55; Rapid Start: 94.8%, n = 55) and Black or African American persons (historical control: 87.9%, n = 51; Rapid Start: 82.8%, n = 48). More patients initiated treatment with an integrase inhibitor-based regimen in the Rapid Start group (98.3%, n = 57) compared with the historical control group (39.7%, n = 23). Compared with controls, the Rapid Start patients were significantly more likely to achieve VS at any given time during the study period (hazard ratio 2.65; p < 0.001). Median days (interquartile range) from diagnosis to VS decreased from 180.5 (102.5-338.5) to 62 (40-105) (p < 0.001), first appointment to VS decreased from 123 (68.5-237.5) to 45 (28-82) (p < 0.001), referral to first visit decreased from 20 (10-43) to 1 (0-3) (p < 0.001), and from first visit to ART dispense date decreased from 27.5 (3-50) to 0 (0-0) (p = 0.01). Prioritizing immediate ART initiation can compress the HIV care continuum from diagnosis to linkage to VS. Implementation of the Rapid Start Protocol should be considered at all VA facilities providing HIV care.

Management of HIV Care in Primary Care Settings

&#x0D; People living with HIV (PLWH) are living longer; this has resulted in the need to manage care for both HIV and non-communicable chronic diseases as these individuals age.&#x0D; The shift of care to primary care physicians from HIV specialists has not generally resulted in a change to patient outcomes.&#x0D; Primary care physicians may need more training to augment their HIV-specific knowledge and increase their comfort and confidence in providing HIV care to PLWH.&#x0D;

A focus on disability is necessary to achieve HIV epidemic control.

Provision of inclusive services and reaching marginalised groups are crucial to achieving the UNAIDS 95-95-95 targets by 2030. However, people with disabilities are often left behind. This gap in HIV care provision is important because more than 1 billion people worldwide have disabilities, including a quarter of people living with HIV. The association between HIV and disability is bidirectional: HIV can cause a range of physical, sensory, and cognitive impairments and people with disabilities are at higher risk of acquiring HIV. People with disabilities often have lower levels of access and adherence to HIV treatment due to barriers with regard to the provision of services (eg, inadequate knowledge among health-care workers and inaccessibility of facilities) and the demand for services (eg, absence of autonomy and awareness of people with disabilities of HIV care needs and service availability). Ultimately, these barriers arise from failures at the system level, including poor governance, leadership, financing, and paucity of data.