Integration Of HIV Treatment Research Articles

Voices from the front lines: A qualitative study of integration of HIV, tuberculosis, and primary healthcare services in Johannesburg, South Africa.

In South Africa, in 2013-2014, provision of antiretroviral treatment (ART) shifted in some areas from NGOs to public facilities. Tuberculosis (TB) management has also been integrated into public services. We aimed to explore the opinions and experiences of service managers and healthcare providers regarding integration of HIV and TB services into primary healthcare services. The study sites included three clinics in one peri-urban/urban administrative region of Johannesburg. From March 2015 to August 2016, trained interviewers conducted semi-structured interviews with purposively selected participants. Participants were eligible if they were city/regional managers, clinic managers, or healthcare providers responsible for HIV, TB, non-communicable diseases, or sexual and reproductive health at the three study sites. We used a grounded theory approach for iterative, qualitative analysis, and produced descriptive statistics for quantitative data. We interviewed 19 individuals (nine city/regional managers, three clinic managers, and seven nurses). Theoretical definitions of integration varied, as did actual practice. Integration of HIV treatment had been anticipated, but only occurred when required due to shifts in funding for ART. The change was rapid, and some clinics felt unprepared. That said, nearly all respondents were in favor of integrated care. Perceived benefits included comprehensive case management, better client-nurse interactions, and reduced stigma. Barriers to integration included staff shortages, insufficient training and experience, and outdated clinic infrastructure. There were also concerns about the impact of integration on staff workloads and waiting times. Finally, there were concerns about TB integration due to infection control issues. Integration is multi-faceted and often contingent on local, if not site-specific, factors. In the future in South Africa and in other settings contending with health service reorganization, staff consultations prior to and throughout phase-in of services changes could contribute to improved understanding of operational requirements, including staff needs, and improved patient outcomes.

When donor funding leaves: an interrupted time-series analysis of the impact of integrating direct HIV care and treatment into public health services in a region of Johannesburg

BackgroundEarly in South Africa’s HIV response, donor-funded organizations directly provided HIV treatment through Comprehensive HIV Care, Management and Treatment sites (CCMTs), using their own and government staff. From 2012 to 2014 the donor-funded CCMT model was phased out, leaving nurses in South Africa’s public clinics responsible for delivery of antiretroviral treatment (ART) services. We aimed to examine the impact on resources, staff workloads, and service delivery throughout this period of integration of HIV treatment into primary health clinics.MethodsWe conducted an Interrupted Time-Series Analysis (ITSA) using data from three public clinics, including one former CCMT site, in one administrative region of Johannesburg. The ITSA was complemented by visual inspection of the data in Excel. We compared trends in expenditure, clinical staffing levels, patient headcounts, and services rendered at the clinics during four periods: pre-CCMT (2004–2007), CCMT operational (2007–2012), CCMT closure (2012–2014), and post-CCMT (2014–2016). Data were drawn from the country’s District Health Information System, a national HIV treatment database, local budget and expenditure reports, National Health Laboratory Service charge records, and staff records.ResultsClosure of the CCMT differentially impacted the study clinics. As expected, ART services decreased at Clinic 1, where the CCMT was co-located, and increased at Clinics 2 and 3 possibly reflecting redistribution of patients. Despite a reduction in patient headcounts post-CCMT, Clinic 1 experienced a decrease in staff and a large increase in patients seen per clinical staff member per month. In contrast, Clinics 2 and 3 increased or maintained stable workforces, and staff workloads post closure were similar to pre-closure levels. Other primary care services—contraception and immunisations—seemed largely unaffected at Clinics 1 and 2. At Clinic 3, service delivery reduced, but this was accompanied by lowered patient headcounts generally, likely due to clinic renovations.ConclusionsIn this study, integration of HIV treatment into primary healthcare services did not result in large-scale reductions in overall service delivery. One facility did experience increased staff workloads, but we were unable to assess service quality. To mitigate potential problems, monitoring systems should be introduced in advance and acknowledge the disparate and decentralised management of various data sources.

Long-term adherence to antiretroviral therapy in a South African adult patient cohort: a retrospective study

BackgroundSouth Africa has the highest HIV prevalence and supports the largest antiretroviral therapy (ART) programme globally. With the introduction of a test and treat policy, ensuring long term optimal adherence to ART (≥95%) is essential for successful patient and public health outcomes. The aim of this study was to assess long-term ART adherence to inform best practices for chronic HIV care.MethodLong-term ART adherence was retrospectively analysed over a median duration of 5 years (interquartile range [IQR]: 5.3–6.5) in patients initially enrolled in a randomised controlled trial assessing tuberculosis and HIV treatment integration and subsequently followed post-trial in an observational cohort study in Durban, South Africa. The association between baseline patient characteristics and adherence over time was estimated using generalized estimating equations (GEE). Adherence was assessed using pharmacy pill counts conducted at each study visit and compared to 6 monthly viral load measurements. A Kaplan Meier survival analysis was used to estimate time to treatment failure. The McNemar test (with exact p-values) was used to determine the effect of pill burden and concurrent ART and tuberculosis treatment on adherence.ResultsOf the 270 patients included in the analysis; 54.8% were female, median age was 34 years (IQR:29–40) and median time on ART was 70 months (IQR = 64–78). Mean adherence was ≥95% for each year on ART. Stable patients provided with an extended 3-month ART supply maintained adherence > 99%. At study end, 96 and 94% of patients were optimally adherent and virologically suppressed, respectively. Time since ART initiation, female gender and primary breadwinner status were significantly associated with ≥95% adherence to ART. The cumulative probability of treatment failure was 10.7% at 5 years after ART initiation. Concurrent ART and tuberculosis treatment, or switching to a second line ART regimen with higher pill burden, did not impair ART adherence.ConclusionOptimal long-term adherence with successful treatment outcomes are possible within a structured ART programme with close adherence monitoring. This adherence support approach is relevant to a resource limited setting adopting a test and treat strategy.

Challenges faced by caregivers of virally non-suppressed children on the intensive adherence counselling program in Uganda: a qualitative study

BackgroundOf the estimated 130,000 children living with HIV in Uganda, 47% are receiving ART. Only 39.3% have suppressed HIV-1 viral load to levels below 50 copies per ml. Caregivers are key drivers of adherence to achieve viral suppression in children. We investigated the challenges and potential support required by caregivers of ART-treated children.MethodsA qualitative study was conducted within the Infectious Diseases Institute paediatric ART program in Kampala and Hoima districts. Caregivers of children with viral loads above 1000 copies were purposively sampled and engaged in five focus group discussions (FGD). The FGD guide highlighted questions on challenges that caregivers face and the kind of support they required to improve children’s ART adherence. Thematic analysis using the inductive approach was used. All the transcripts were read, coded and emergent themes determined.ResultsOverall, 37 caregivers participated in five FGD, of whom 29 (78%) were female, 28 (76%) were HIV-infected and 25 (68%) were biological parents of the children. The elicited challenges were either in failure to attend the counselling sessions or in supporting adherence to medication. Individual and health system challenges such as competing priorities, logistics, poor quality of counselling and lack of reminders prevented attendance at counselling sessions. Five themes emerged as challenges to supporting adherence: i) environmental (school activities, working away from home), ii) personal (non-disclosure, stigma), iii) psychological (guilt), iv) financial (lack of food and transport) and v) child-related (fatigue and peer influence). Three major themes emerged for the support that caregivers needed namely: a) health system reforms (clinic appointments outside school hours, minimize ART drug stock outs and improve quality of counselling), b) psychosocial support (support with disclosure of HIV status to children and their families, more frequent peer support groups and parenting classes) and c) economic empowerment (training in vocational skills, school fees support and opportunities to initiate income generating activities).Discussion and conclusionTo achieve viral suppression, ART programs require targeted efforts to provide specific health facility requirements, psychological and economic needs of ART-treated children and their caregivers. Integration of HIV treatment with programs for orphans and vulnerable children may improve viral suppression rates.

Improving survival with tuberculosis & HIV treatment integration: A mini-review.

Tuberculosis (TB) is a leading cause of morbidity and mortality among HIV-infected patients while HIV remains a key risk factor for the development of active TB infection. Treatment integration is a key in reducing mortality in patients with HIV-TB co-infection. However, this opportunity to improve outcomes of both infections is often missed or poorly implemented. Challenges in TB-HIV treatment integration range from complexities involving clinical management of co-infected patients to obstacles in health service-organization and prioritization. This is evident in high prevalence settings such as in sub-Saharan Africa where TB-HIV co-infection rates reach up to 80 per cent. This review discusses published literature on clinical trials and cohort studies of strategies for TB-HIV treatment integration aimed at reducing co-infection mortality. Studies published since 2009, when several treatment guidelines recommended treatment integration, were included. A total of 43 articles were identified, of which a total of 23 observational studies and nine clinical trials were informative on TB-HIV treatment integration. The data show that the survival benefit of AIDS therapy in patients infected with TB can be maximized among patients with advanced immunosuppression by starting antiretroviral therapy (ART) soon after TB treatment initiation, i.e. in patients with CD4+ cell counts <50 cells/μl. However, patients with greater CD4+ cell counts should defer initiation of ART to no less than eight weeks after initiation of TB treatment to reduce the occurrence and extent of immune reconstitution disease and subsequent hospitalization. Addressing operational challenges in integrating TB-HIV care can significantly improve patient outcomes, generate substantial public health impact by decreasing morbidity and death in settings with a high burden of HIV and TB.

Addressing challenges in scaling up TB and HIV treatment integration in rural primary healthcare clinics in South Africa (SUTHI): a cluster randomized controlled trial protocol

Addressing challenges in scaling up TB and HIV treatment integration in rural primary healthcare clinics in South Africa (SUTHI): a cluster randomized controlled trial protocol

Implementation and Operational Research: Effects of Antenatal Care and HIV Treatment Integration on Elements of the PMTCT Cascade: Results From the SHAIP Cluster-Randomized Controlled Trial in Kenya.

Integrating antenatal care (ANC) and HIV care may improve uptake and retention in services along the prevention of mother-to-child transmission (PMTCT) cascade. This study aimed to determine whether integration of HIV services into ANC settings improves PMTCT service utilization outcomes. ANC clinics in rural Kenya were randomized to integrated (6 clinics, 569 women) or nonintegrated (6 clinics, 603 women) services. Intervention clinics provided all HIV services, including highly active antiretroviral therapy (HAART), whereas control clinics provided PMTCT services but referred women to HIV care clinics within the same facility. PMTCT utilization outcomes among HIV-infected women (maternal HIV care enrollment, HAART initiation, and 3-month infant HIV testing uptake) were compared using generalized estimating equations and Cox regression. HIV care enrollment was higher in intervention compared with control clinics [69% versus 36%; odds ratio = 3.94, 95% confidence interval (CI): 1.14 to 13.63]. Median time to enrollment was significantly shorter among intervention arm women (0 versus 8 days, hazard ratio = 2.20, 95% CI: 1.62 to 3.01). Eligible women in the intervention arm were more likely to initiate HAART (40% versus 17%; odds ratio = 3.22, 95% CI: 1.81 to 5.72). Infant testing was more common in the intervention arm (25% versus 18%), however, not statistically different. No significant differences were detected in postnatal service uptake or maternal retention. Service integration increased maternal HIV care enrollment and HAART uptake. However, PMTCT utilization outcomes were still suboptimal, and postnatal service utilization remained poor in both study arms. Further improvements in the PMTCT cascade will require additional research and interventions.

Effect of HIV status on fertility intention and contraceptive use among women in nine sub-Saharan African countries: evidence from Demographic and Health Surveys

BackgroundExpanding access to antiretroviral therapy (ART) means that HIV is no longer a death sentence. This change has implications for reproductive decisions and behaviors of HIV-infected individuals.DesignUsing multiple rounds of biomarker data from Demographic and Health Surveys (2004–2012) in nine sub-Saharan African countries, we compare patterns of associations between HIV status and fertility intention and between current use of modern contraception and HIV status in the context of expanding ART coverage.ResultsGenerally, results show that knowledge of HIV status and proportion of women ever tested for HIV increased substantially between the two surveys for almost all countries. Whereas modern contraceptive use slightly increased, fertility intentions remained relatively stable, except for Rwanda, where they decreased. Results from the two surveys for the nine countries do however indicate that there is no clear consistent pattern of fertility intention and modern contraceptive use behavior by HIV status, with variations observed across countries. However, multivariate analyses show that for Rwanda and Zimbabwe women who were HIV positive, with knowledge of their status, had lower odds of wanting more children. Similarly only in Rwanda (both surveys) were HIV-positive women who knew their status more likely to be current users of contraception compared with women who were HIV negative. The reverse was observed for Zimbabwe.ConclusionsGenerally, the results point to the fact that the assumption that reproductive intention and behavior of HIV-positive women will differ compared with that of HIV-negative women may only hold true to the extent that women know their HIV status. Continuous expansion of voluntary counseling and testing services and integration of HIV treatment and care services with reproductive health services are thus warranted.

Integrating HIV treatment with primary care outpatient services: opportunities and challenges from a scaled-up model in Zambia

Background Integration of HIV treatment with other primary care services has been argued to potentially improve effectiveness, efficiency and equity. However, outside the field of reproductive health, there is limited empirical evidence regarding the scope or depth of integrated HIV programmes or their relative benefits. Moreover, the body of work describing operational models of integrated service-delivery in context remains thin. Between 2008 and 2011, the Lusaka District Health Management Team piloted and scaled-up a model of integrated HIV and general outpatient department (OPD) services in 12 primary health care clinics. This paper examines the effect of the integrated model on the organization of clinic services, and explores service providers’ perceptions of the integrated model.Methods We used a mixed methods approach incorporating facility surveys and key informant interviews with clinic managers and district officials. On-site facility surveys were carried out in 12 integrated facilities to collect data on the scope of integrated services, and 15 semi-structured interviews were carried out with 12 clinic managers and three district officials to explore strengths and weaknesses of the model. Quantitative and qualitative data were triangulated to inform overall analysis.Findings Implementation of the integrated model substantially changed the organization of service delivery across a range of clinic systems. Organizational and managerial advantages were identified, including more efficient use of staff time and clinic space, improved teamwork and accountability, and more equitable delivery of care to HIV and non-HIV patients. However, integration did not solve ongoing human resource shortages or inadequate infrastructure, which limited the efficacy of the model and were perceived to undermine service delivery.Conclusion While resource and allocative efficiencies are associated with this model of integration, a more important finding was the model’s demonstrated potential for strengthening organizational culture and staff relationships, in turn facilitating more collaborative and motivated service delivery in chronically under-resourced primary healthcare clinics.

Conceptualizing the integration of HIV treatment and prevention: findings from a process evaluation of a community-based, national capacity-building intervention

This paper responds to a gap in knowledge about the conceptualization of integration in community-based AIDS organizations (CBAOs). A community-based process evaluation was conducted of a national intervention, developed by the Canadian AIDS Treatment Information Exchange (CATIE), to enhance treatment information provision in CBAOs and encourage its integration with prevention services. Our study involved 13 interviews with intervention participants in 6 CBAOs across Canada, CATIE staff, and funders, as well as a 25-person verification exercise. Intervention participants conceptualized integration as linking front-line HIV treatment, health promotion and prevention services, emphasizing mediation between scientific and lay knowledge, the political context of integration and the role of social determinants in clients' health and access to services. Challenges to integration include high staff turnover and inflexible funding structures. Complex health education related to the relationship between viral load and HIV transmission is a critical area of integrated service delivery. Study findings help distinguish a community-based concept of HIV-related integration from alternative uses of the term while pointing out key tensions associated with efforts to integrate HIV prevention and treatment in a community-based context.

Beyond buzzwords: toward a community-based model of the integration of HIV treatment and prevention

Propelled by increased global access to Highly Active Anti-Retroviral Therapies, the integration of HIV treatment and prevention has emerged as an important organizing concept of pandemic response. Despite its potential significance for community-based AIDS organizations (CBAOs) little research on integration has been done from a community-based perspective. This paper responds to that gap in the literature. With a view to moving what can be an abstract concept to the level of concrete practice, we offer a community-based model of the integration of HIV treatment and prevention. The model is based on research conducted in 2006–2007 with front-line staff from CBAOs across Canada carried out in partnership with the Canadian AIDS Treatment Information Exchange. The model is grounded in three central dimensions of a community-based perspective on integration deriving from our research: the phenomenological primacy of front-line service work, a comprehensive notion of treatment and prevention, and the importance of social context. The model is intended as a conceptual resource that can assist CBAOs in formulating practical responses to new demands for integrated service provision.