non-HIV Services Research Articles

Effect of HIV-Integrated Care on Uptake of Maternal Health and Routine Childhood Immunization Services at Primary Health Care Facility in Northern Nigeria: An Interrupted Time Series Analysis

Background: This study assessed the effect of HIV-integrated care delivered within routine primary health care (PHC) in Kano, Nigeria, on the uptake of maternal health and routine childhood immunization services. Methods: A retrospective cohort design was used to review and collect anonymized data from medical records of women and children who accessed health care from the PHC facility between January 2009 and December 2016. Data were analyzed using SPSS version 22. Interrupted time series analysis (ITS) was performed to estimate changes in maternal and childhood immunization service usage over time following the delivery of the integrated care. Results: Uptake of maternal health services increased over time: antenatal care attendance (effect/month [95% confidence interval (CI)]: 6.6 [44.55–8.65], P = 0.0001), family planning (effect/month [95% CI]: 1.3 [0.26–2.26], P = 0.014), and delivery (effect/month [95% CI]: 0.9 [0.39–1.45], P = 0.0009). Uptake of routine immunization also increased over time with the integrated care: Bacille Calmette Guerin (BCG) (Effect/month [95% CI]: 1.8 [0.64–2.88], P = 0.002), and diphtheria, tetanus, and pertussis 1 (DPT1)/Penta 1 vaccinations (Effect/month [95% CI]: 1.0 [0.20–1.73], P = 0.013) also showed a moderate increase over time, but DPT3/Penta 3 vaccination dropped gradually over time (Effect/month [95% CI]: −0.1 [−0.74–0.46], P = 0.649). Conclusion: The integrated care resulted in increased uptake of both maternal health and childhood routine immunization services. This suggests that the reorganization and restructuring of the HIV-integrated care in the Kumbotso Comprehensive Health Centre has had a positive impact on non-HIV services provided at the center. There are still opportunities for further research to refine and elaborate on the novel findings of this study.

Unmet Needs for HIV Ancillary Services Among Persons With Diagnosed HIV Aged 55 years and Older.

Approximately 2 in 5 persons with HIV (PWH) in the United States are aged 55 years or older. HIV ancillary services, such as case management and transportation services, can help older PWH remain engaged in care. We used data from the Medical Monitoring Project (MMP) to describe the prevalence of unmet needs for ancillary services among persons with diagnosed HIV aged 55 years or older. MMP is an annual cross-sectional study that reports representative estimates on adults with diagnosed HIV in the United States. We used MMP data collected during June 2019-May 2021 to calculate weighted percentages of cisgender men and cisgender women with HIV aged 55 years or older with unmet needs for ancillary services, overall and by selected characteristics (N = 3200). Unmet need was defined as needing but not receiving a given ancillary service. We assessed differences between groups using prevalence ratios (PRs) and 95% confidence intervals with predicted marginal means. Overall, 37.7% of cisgender men and women with HIV aged 55 years or older had ≥1 unmet need for ancillary services. Overall, 16.6% had ≥1 unmet need for HIV support services, 26.9% for non-HIV medical services, and 26.7% for subsistence services. There were no statistically significant differences in unmet needs for services by gender. The prevalence of ≥1 unmet need was higher among non-White persons (PR range: 1.35-1.63), persons who experienced housing instability (PR = 1.70), and those without any private insurance (PR range: 1.49-1.83). A large percentage of older PWH have unmet needs for ancillary services. Given the challenges that older PWH face related to the interaction of HIV and aging-associated factors, deficits in the provision of ancillary services should be addressed.

Multidisciplinary working in a community HIV specialist service.

A documentation audit was performed to explore the multidisciplinary working of a community HIV specialist service (CHSS). The audit identified the wide range of services to which people living with HIV are referred as part of the care they receive within the CHSS. A retrospective documentation audit was used. The CHSS, consisting of three teams covering a wide geographical area across West Sussex and Brighton and Hove. A total of 30 patients' notes were audited, including 10 patients from each team to ensure the results were representative of the service as a whole. The audit showed that, on average, each person received five onward referrals to other health care, social care, or HIV-specific services, with a range of between 1 and 12, as a result of being under the care of the CHSS. The types of referrals varied, with 46% being to HIV specialist services and the remaining 54% to non-HIV specific services, including GPs, social services and other health services. Overall, the audit showed not only the holistic care and assessments completed but also the benefit and increased access to other services and care as a result of community HIV team involvement. The audit highlights the importance of continuing to develop HIV community services to cater for this changing population, as well as identifying possible areas of development. The results also demonstrate the vital role that CHSSs have in supporting hard-to-reach patients.

Clinic-level complexities prevent effective engagement of people living with HIV who are out-of-care.

Approximately half of people living with HIV (PLWH) in the United States are not retained in HIV care. Although numerous studies have identified individual-level barriers to care (i.e., substance abuse, mental health, housing, transportation challenges), less is known about institutional-level barriers. We aimed to identify clinic-level barriers to HIV care and strategies to address them to better engage PLWH who have been out of care (PLWH-OOC). As part of a larger qualitative study in a Ryan White-funded HIV Clinic in Atlanta, which aimed to understand the acceptance and feasibility of community-based HIV care models to better reach PLWH-OOC, we explored barriers and facilitators of HIV care engagement. From October 2022-March 2023, 18 in-depth-interviews were conducted with HIV-care providers, administrators, social workers, and members of a Community Advisory Board (CAB) comprised of PLWH-OOC. Transcripts were coded by trained team members using a consensus approach. Several clinic-level barriers emerged: 1) the large burden placed on patients to provide proof of eligibility to receive Ryan White Program services, 2) inflexibility of provider clinic schedules, 3) inadequate processes to identify patients at risk of disengaging from care, 4) poorly-resourced hospital-to-clinic transitions, 5) inadequate systems to address primary care needs outside of HIV care, and 6) HIV stigma among medical professionals. Strategies to address these barriers included: 1) colocation of HIV and non-HIV services, 2) community-based care options that do not require patients to navigate complex transportation systems, 3) hospital and community-based peer navigation services, 4) dedicated staffing to identify and support PLWH-OOC, and 5) enhanced systems support to help patients collect the high burden of documentation required to receive subsidized HIV care. Several systems-level HIV care barriers exist and intersect with individual and community-level barriers to disproportionately affect HIV care engagement among PLWH-OOC. Findings suggest several strategies that should be considered to reach the remaining 50% of PLWH who remain out-of-care.

Drivers of HIV treatment interruption: Early findings from community-led monitoring program in Haiti.

Failure to retain people living with HIV (PLHIV) in care remains a significant barrier to achieving epidemic control in Haiti, with as many as 30% lost from care within one year of starting treatment. Community-led monitoring (CLM) is an emerging approach of improving healthcare and accountability to service users, through a cycle of monitoring and advocacy. In 2020, a CLM program was launched in Haiti to identify barriers to retention and advocating for better health services. Data from the community-led monitoring program in Haiti were analyzed, from a sample of 65 healthcare facilities in the Nord, Artibonite, and Ouest departments collected from April 2021 to February 2022. Qualitative data from six community-based focus groups and 45 semi-structured individual interviews were analyzed. Confidentiality and stigmatization emerged as barriers to care, particularly due to the separation of PLHIV from other patients in view of community members. To avoid identification, patients described traveling long distances, with the reimbursement of transportation costs described as being insufficient or unavailable. Costs of non-HIV clinical services were a frequent concern and respondents described a need for clinics to provide food during all patient visits. Stock-outs were a regular challenge; by contrast, treatment literacy did not emerge as a major barrier to retention. These findings represent the first instance, to our knowledge, of original data from a community-led monitoring program being published in any country. These findings suggest that improving treatment retention for PLHIV is dependent on improving the acceptability and affordability of healthcare services. Ensuring confidentiality is critical, particularly where stigma is high. Retention could be improved by systematically strengthening patient confidentiality protections throughout the healthcare system, providing patients with sufficient travel compensation and other incentives, and delivering wraparound services provided for free. Addressing these challenges will require ongoing advocacy for community-developed recommendations and solutions.

Unmet Needs for Ancillary Services and Associations with Clinical Outcomes Among Transgender Women with Diagnosed HIV: Medical Monitoring Project, United States, 2015-2020.

Purpose: Access to ancillary services-including HIV support services, non-HIV clinical services, and subsistence services-can support care engagement and viral suppression and reduce disparities among people with HIV (PWH). We used representative U.S. data to assess differences in unmet needs for ancillary services between transgender women with HIV and other PWH. In addition, we examined associations between unmet needs and clinical outcomes among transgender women. Methods: We analyzed 2015-2020 Medical Monitoring Project data among transgender women (N = 362), cisgender men (N = 17,319), and cisgender women (N = 6016) with HIV. We reported weighted percentages for characteristics, and reported adjusted prevalence ratios (aPRs) controlling for race/ethnicity and age, and 95% confidence intervals (CI) using logistic regression with predicted marginal means to assess differences between groups. Results: Among transgender women, unmet needs were highest for dental care (24.9%), shelter or housing (13.9%), and transportation assistance (12.6%). Transgender women were more likely than cisgender men to have unmet subsistence needs. Among transgender women, unmet needs for ancillary services were negatively associated with many clinical outcomes after adjusting for age and race/ethnicity. Unmet needs for subsistence services were associated with higher levels of antiretroviral therapy nonadherence (aPR: 1.39; 95% CI: 1.13-1.70) and detectable viral loads (aPR: 1.47; 1.09-1.98), emergency room visits (aPR: 1.42; 1.06-1.90), and depression (aPR: 2.74; 1.83-4.10) or anxiety (aPR: 3.20; 2.05-5.00) symptoms. Conclusions: Transgender women with HIV were more likely than cisgender men with HIV to experience unmet needs for subsistence services-likely a reflection of substantial socioeconomic disadvantage. Addressing unmet needs is an essential step for improving care outcomes among transgender women with HIV.

An exploration of the quality of life of people living with HIV in Greece: Challenges and opportunities.

ObjectiveImproving the quality of life (QoL) of people living with HIV (PLWH) has been proposed as a new priority in HIV care. The objective of this cross-sectional, qualitative study was to explore the perspectives of PLWH in Greece regarding their QoL.DesignTwenty-four semi-structured interviews were conducted with PLWH receiving care across six HIV clinics in Greece. The thematic analysis of the transcribed interviews resulted in four themes and eleven subthemes.ResultsFirst, fear of repercussions (e.g., stigmatization) makes PLWH reluctant to disclose their diagnosis in public settings or disclose accounting for factors like the confidant’s discretion. Second, participants are challenged by HIV’s unique biopsychosocial facets (e.g., uncertainty about symptoms) and fear for the future (e.g., a confidant revealing their HIV status without consent). Third, support received by specialist services is satisfactory in contrast to non-HIV specialist services, where significant improvements are needed to reduce stigmatization. Finally, the experiences of PLWH include contrasting elements of post-traumatic growth and an inability to accept their seropositivity (e.g., avoiding social interactions).ConclusionsEmpowering PLWH in these QoL areas is greatly needed. Increasing the life expectancy of PLWH is only the initial step; their QoL needs to be secured as the next priority in HIV care.

Integrating HIV services and other health services: Asystematic review and meta-analysis.

BackgroundIntegration of HIV services with other health services has been proposed as an important strategy to boost the sustainability of the global HIV response. We conducted a systematic and comprehensive synthesis of the existing scientific evidence on the impact of service integration on the HIV care cascade, health outcomes, and cost-effectiveness.Methods and findingsWe reviewed the global quantitative empirical evidence on integration published between 1 January 2010 and 10 September 2021. We included experimental and observational studies that featured both an integration intervention and a comparator in our review. Of the 7,118 unique peer-reviewed English-language studies that our search algorithm identified, 114 met all of our selection criteria for data extraction. Most of the studies (90) were conducted in sub-Saharan Africa, primarily in East Africa (55) and Southern Africa (24). The most common forms of integration were (i) HIV testing and counselling added to non-HIV services and (ii) non-HIV services added to antiretroviral therapy (ART). The most commonly integrated non-HIV services were maternal and child healthcare, tuberculosis testing and treatment, primary healthcare, family planning, and sexual and reproductive health services. Values for HIV care cascade outcomes tended to be better in integrated services: uptake of HIV testing and counselling (pooled risk ratio [RR] across 37 studies: 1.67 [95% CI 1.41–1.99], p < 0.001), ART initiation coverage (pooled RR across 19 studies: 1.42 [95% CI 1.16–1.75], p = 0.002), time until ART initiation (pooled RR across 5 studies: 0.45 [95% CI 0.20–1.00], p = 0.050), retention in HIV care (pooled RR across 19 studies: 1.68 [95% CI 1.05–2.69], p = 0.031), and viral suppression (pooled RR across 9 studies: 1.19 [95% CI 1.03–1.37], p = 0.025). Also, treatment success for non-HIV-related diseases and conditions and the uptake of non-HIV services were commonly higher in integrated services. We did not find any significant differences for the following outcomes in our meta-analyses: HIV testing yield, ART adherence, HIV-free survival among infants, and HIV and non-HIV mortality. We could not conduct meta-analyses for several outcomes (HIV infections averted, costs, and cost-effectiveness), because our systematic review did not identify sufficient poolable studies. Study limitations included possible publication bias of studies with significant or favourable findings and comparatively weak evidence from some world regions and on integration of services for key populations in the HIV response.ConclusionsIntegration of HIV services and other health services tends to improve health and health systems outcomes. Despite some scientific limitations, the global evidence shows that service integration can be a valuable strategy to boost the sustainability of the HIV response and contribute to the goal of ‘ending AIDS by 2030’, while simultaneously supporting progress towards universal health coverage.

Effects of transition on HIV and non-HIV services and health systems in Kenya: a mixed methods evaluation of donor transition

BackgroundIn 2015 the US President’s Emergency Plan for AIDS Relief (PEPFAR) initiated its Geographic Prioritization (GP) process whereby it prioritized high burden areas within countries, with the goal of more rapidly achieving the UNAIDS 90–90-90 targets. In Kenya, PEPFAR designated over 400 health facilities in Northeastern Kenya to be transitioned to government support (known as central support (CS)).MethodsWe conducted a mixed methods evaluation exploring the effect of GP on health systems, and HIV and non-HIV service delivery in CS facilities. Quantitative data from a facility survey and health service delivery data were gathered and combined with data from two rounds of interviews and focus group discussions (FGDs) conducted at national and sub-national level to document the design and implementation of GP. The survey included 230 health facilities across 10 counties, and 59 interviews and 22 FGDs were conducted with government officials, health facility providers, patients, and civil society.ResultsWe found that PEPFAR moved quickly from announcing the GP to implementation. Despite extensive conversations between the US government and the Government of Kenya, there was little consultation with sub-national actors even though the country had recently undergone a major devolution process. Survey and qualitative data identified a number of effects from GP, including discontinuation of certain services, declines in quality and access to HIV care, loss of training and financial incentives for health workers, and disruption of laboratory testing. Despite these reports, service coverage had not been greatly affected; however, clinician strikes in the post-transition period were potential confounders.ConclusionsThis study found similar effects to earlier research on transition and provides additional insights about internal country transitions, particularly in decentralized contexts. Aside from a need for longer planning periods and better communication and coordination, we raise concerns about transitions driven by epidemiological criteria without adaptation to the local context and their implication for priority-setting and HIV investments at the local level.

Understanding and addressing privacy and confidentiality concerns associated with the provision of mobile HIV care: a qualitative study

ABSTRACT Less than half the people with HIV (PLWH) in the United States (US) are retained in HIV care, underscoring the importance of novel reengagement and retention strategies. Mobile HIV clinics (MHCs) are one such strategy, but privacy and confidentiality concerns have limited their use. As part of a larger mixed-methods study in Atlanta, Georgia, from June 2019- July 2020, we conducted 41 qualitative interviews with key stakeholders to explore confidentiality, privacy and stigma concerns and strategies to address them. Interviews were recorded, transcribed and coded thematically. Four key themes emerged: 1) the need to understand MHC acceptance in the context of high HIV stigma in the South, 2) the multidimensionality of confidentiality and stigma concerns (e.g., related to exterior labeling, layout, location attracting unwanted attention), 3) the counter perspective: potential for MHCs to positively reframe HIV and reduce stigma, and 4) strategies to overcome stigma and confidentiality concerns, including co-delivery of non-HIV services, unidirectional flow, and non-HIV exterior labeling. In furthering understanding of the breadth of privacy and confidentiality concerns associated with an MHC and strategies for addressing them, this exploratory study lays a critical foundation for the development of an MHC to reengage and retain PLWH in the US.

Barriers and facilitators to use of a mobile HIV care model to re-engage and retain out-of-care people living with HIV in Atlanta, Georgia.

Novel strategies to re-engage and retain people living with HIV (PLWH) who are out of care are greatly needed. While mobile clinics have been used effectively for HIV testing and linkage, evidence guiding their use in providing HIV care domestically has been limited. To guide the development of a mobile HIV clinic (MHC) model as a strategy to re-engage and retain PLWH who are out of care, we aimed to explore stakeholder perceptions of barriers and facilitators to MHC implementation and use. From June 2019-July 2020, we conducted 41 in-depth interviews with HIV clinic providers, administrators, staff, legal authorities, and community advisory board members, PLWH, AIDS service organizations and city officials in Atlanta, Georgia, and domestic and international mobile health clinics to explore barriers and facilitators to use of MHCs. Interviews were transcribed, coded and thematically analysed. Barriers raised include potential for: breach of confidentiality with resulting heightened stigmatization, fractured continuity of care, safety concerns, staffing challenges, and low community acceptance of MHC presence in their locality. Participants provided suggestions regarding appropriate exterior design, location, timing, and co-delivery of non-HIV services that could facilitate MHC acceptance and address the concerns. In identifying key barriers and facilitators to MHC use, this study informs design and implementation of an MHC as a novel strategy for re-engaging and retaining PLWH who are out of care.

HIV screening in dental settings: Challenges, opportunities, and a call to action.

HIV is responsible for tremendous suffering and loss around the world, but many advances in HIV screening, diagnosis, treatment, and prevention provide hope for an end to the HIV epidemic. Global and national campaigns facilitate access to these HIV advances, but some individuals and communities still lack access, particularly in developing countries. To reach those who remain under-served, campaigns encourage greater integration of HIV services with non-HIV services. As members of the healthcare team with a clinical stake in HIV, dental care providers have a unique contribution to make. Much research on the role of dental care providers in HIV has focused on HIV screening in the dental setting, and researchers have identified possible ways forward but also daunting challenges. Approaches for screening, brief intervention, and referral to treatment used in primary care and dental care settings for other health risks may help overcome challenges related to provider scope of practice and need for training. Approaches to managing distress and uncertainty in other clinical contexts may help overcome challenges related to patient acceptability, equipping providers to manage sensitive topics and emotional aspects of HIV screening. While not panaceas, these approaches may be useful to dental care providers interested in answering the global "call to action" for contributing to ending the HIV epidemic.

Global and regional trends of people living with HIV aged 50 and over: Estimates and projections for 2000-2020.

BackgroundThe increasing numbers of people living with HIV (PLHIV) who are receiving antiretroviral therapy (ART) have near normal life-expectancy, resulting in more people living with HIV over the age of 50 years (PLHIV50+). Estimates of the number of PLHIV50+ are needed for the development of tailored therapeutic and prevention interventions at country, regional and global level.MethodsThe AIDS Impact Module of the Spectrum software was used to compute the numbers of PLHIV, new infections, and AIDS-related deaths for PLHIV50+ for the years 2000–2016. Projections until 2020 were calculated based on an assumed ART scale-up to 81% coverage by 2020, consistent with the UNAIDS 90–90–90 treatment targets.ResultsGlobally, there were 5.7 million [4.7 million– 6.6 million] PLHIV50+ in 2016. The proportion of PLHIV50+ increased substantially from 8% in 2000 to 16% in 2016 and is expected to increase to 21% by 2020. In 2016, 80% of PLHIV50+ lived in low- and middle-income countries (LMICs), with Eastern and Southern Africa containing the largest number of PLHIV50+. While the proportion of PLHIV50+ was greater in high income countries, LMICs have higher numbers of PLHIV50+ that are expected to continue to increase by 2020.ConclusionsThe number of PLHIV50+ has increased dramatically since 2000 and this is expected to continue by 2020, especially in LMICs. HIV prevention campaigns, testing and treatment programs should also focus on the specific needs of PLHIV50+. Integrated health and social services should be developed to cater for the changing physical, psychological and social needs of PLHIV50+, many of whom will need to use HIV and non-HIV services.

Provider perspectives on PrEP for adolescent girls and young women in Tanzania: The role of provider biases and quality of care.

BackgroundOral pre-exposure prophylaxis (PrEP) has the potential to reduce HIV acquisition among adolescent girls and young women (AGYW) in sub-Saharan Africa. However, health care providers’ (HCPs) perspectives and interactions with potential clients can substantially influence effective provision of quality health services. We examine if HCPs’ knowledge, attitude, and skills, as well as their perceptions of facility readiness to provide PrEP are associated with their willingness to provide PrEP to AGYW at high risk of HIV in Tanzania.MethodsA self-administered questionnaire was given to 316 HCPs from 74 clinics in two districts and 24 HCPs participated in follow-up in-depth interviews (IDIs). We conducted bivariate and multivariable Poisson regression to assess factors associated with willingness to provide PrEP to AGYW. Thematic content analysis was used to analyze the IDIs, which expanded upon the quantitative results.ResultsFew HCPs (3.5%) had prior PrEP knowledge, but once informed, 61.1% were willing to prescribe PrEP to AGYW. Higher negative attitudes toward adolescent sexuality and greater concerns about behavioral disinhibition due to PrEP use were associated with lower willingness to prescribe PrEP. Qualitatively, HCPs acknowledged that biases, rooted in cultural norms, often result in stigmatizing and discriminatory care toward AGYW, a potential barrier for PrEP provision. However, better training to provide HIV services was associated with greater willingness to prescribe PrEP.Conversely, HCPs feared the potential negative impact of PrEP on the provision of existing HIV services (e.g., overburdened staff), and suggested the integration of PrEP into non-HIV services and the use of paramedical professionals to facilitate PrEP provision.ConclusionsPreparing for PrEP introduction requires more than solely training HCPs on the clinical aspects of providing PrEP. It requires a two-pronged strategy: addressing HCPs’ biases regarding sexual health services to AGYW; and preparing the health system infrastructure for the introduction of PrEP.

The effect of facility-based antiretroviral therapy programs on outpatient services in Kenya and Uganda

BackgroundConsiderable debate exists concerning the effects of antiretroviral therapy (ART) service scale-up on non-HIV services and overall health system performance in sub-Saharan Africa. In this study, we examined whether ART services affected trends in non-ART outpatient department (OPD) visits in Kenya and Uganda.MethodsUsing a nationally representative sample of health facilities in Kenya and Uganda, we estimated the effect of ART programs on OPD visits from 2007 to 2012. We modeled the annual percent change in non-ART OPD visits using hierarchical mixed-effects linear regressions, controlling for a range of facility characteristics. We used four different constructs of ART services to capture the different ways in which the presence, growth, overall, and relative size of ART programs may affect non-ART OPD services.ResultsOur final sample included 321 health facilities (140 in Kenya and 181 in Uganda). On average, OPD and ART visits increased steadily in Kenya and Uganda between 2007 and 2012. For facilities where ART services were not offered, the average annual increase in OPD visits was 4·2% in Kenya and 13·5% in Uganda. Among facilities that provided ART services, we found average annual OPD volume increases of 7·2% in Kenya and 5·6% in Uganda, with simultaneous annual increases of 13·7% and 12·5% in ART volumes. We did not find a statistically significant relationship between annual changes in OPD services and the presence, growth, overall, or relative size of ART services. However, in a subgroup analysis, we found that Ugandan hospitals that offered ART services had statistically significantly less growth in OPD visits than Ugandan hospitals that did not provide ART services.ConclusionsOur findings suggest that ART services in Kenya and Uganda did not have a statistically significant deleterious effects on OPD services between 2007 and 2012, although subgroup analyses indicate variation by facility type. Our findings are encouraging, particularly given recent recommendations for universal access to ART, demonstrating that expanding ART services is not inherently linked to declines in other health services in sub-Saharan Africa.

The relationship between health worker stigma and uptake of HIV counseling and testing and utilization of non-HIV health services: the experience of male and female sex workers in Kenya

ABSTRACTThe barrier HIV-stigma presents to the HIV treatment cascade is increasingly documented; however less is known about female and male sex worker engagement in and the influence of sex-work stigma on the HIV care continuum. While stigma occurs in all spheres of life, stigma within health services may be particularly detrimental to health seeking behaviors. Therefore, we present levels of sex-work stigma from healthcare workers (HCW) among male and female sex workers in Kenya, and explore the relationship between sex-work stigma and HIV counseling and testing. We also examine the relationship between sex-work stigma and utilization of non-HIV health services. A snowball sample of 497 female sex workers (FSW) and 232 male sex workers (MSW) across four sites was recruited through a modified respondent-driven sampling process. About 50% of both male and female sex workers reported anticipating verbal stigma from HCW while 72% of FSW and 54% of MSW reported experiencing at least one of seven measured forms of stigma from HCW. In general, stigma led to higher odds of reporting delay or avoidance of counseling and testing, as well as non-HIV specific services. Statistical significance of relationships varied across type of health service, type of stigma and gender. For example, anticipated stigma was not a significant predictor of delay or avoidance of health services for MSW; however, FSW who anticipated HCW stigma had significantly higher odds of avoiding (OR = 2.11) non-HIV services, compared to FSW who did not. This paper adds to the growing evidence of stigma as a roadblock in the HIV treatment cascade, as well as its undermining of the human right to health. While more attention is being paid to addressing HIV-stigma, it is equally important to address the key population stigma that often intersects with HIV-stigma.

Client uptake of safer conception strategies: implementation outcomes from the Sakh'umndeni Safer Conception Clinic in South Africa.

Introduction: Implementation of safer conception services for HIV-affected couples within primary healthcare clinics in resource-limited settings remains limited. We review service utilization and safer conception strategy uptake during the first three years of Sakh’umndeni, which is a safer conception clinic in South Africa.Methods: Sakh’umndeni is located at Witkoppen Health and Welfare Centre, a high-volume primary healthcare clinic in northern Johannesburg. Men and women desiring to conceive in less than or equal to six months and in relationships in which one or both partners are living with HIV are eligible for safer conception services. Clients receive a baseline health assessment and counselling around periconception HIV risk reduction strategies and choose which strategies they plan to use. Clients are followed-up monthly. We describe client service utilization and uptake and continuation of safer conception methods. Factors associated with male partner attendance are assessed using robust Poisson regression.Results: Overall 440 individuals utilized the service including 157 couples in which both partners attended (55%) and 126 unaccompanied female partners. Over half of the couples (55%) represented were in serodiscordant/unknown status relationships. Higher economic status and HIV-negative status of the women increased male partner involvement, while HIV-negative status of the men decreased male involvement. Regarding safer conception strategies, uptake of antiretroviral therapy initiation (90%), vaginal self-insemination among partnerships with HIV-negative men (75%) and timed condomless intercourse strategies (48%) were variable, but generally high. Overall uptake of pre-exposure prophylaxis (PrEP) was 23% and was lower among HIV-negative men than women (7% vs. 44%, p < 0.001). Male medical circumcision (MMC) was used by 28% of HIV-negative men. Over 80% of clients took up at least one recommended safer conception strategy. Continuation of selected strategies over attempted conception attempts was >60%.Conclusions: Safer conception strategies are generally used by clients per recommendations. High uptake of strategies suggests that the proposed combination prevention methods are acceptable to clients and appropriate for scale-up; however, low uptake of PrEP and MMC among HIV-negative men needs improvement. Targeted community-based efforts to reach men unlinked to safer conception services are needed, alongside streamlined approaches for service scale-up within existing HIV and non-HIV service delivery platforms.

How Can the Health System Retain Women in HIV Treatment for a Lifetime? A Discrete Choice Experiment in Ethiopia and Mozambique.

IntroductionOption B+, an approach that involves provision of antiretroviral therapy (ART) to all HIV-infected pregnant women for life, is the preferred strategy for prevention of mother to child transmission of HIV. Lifelong retention in care is essential to its success. We conducted a discrete choice experiment in Ethiopia and Mozambique to identify health system characteristics preferred by HIV-infected women to promote continuity of care.MethodsWomen living with HIV and receiving care at hospitals in Oromia Region, Ethiopia and Zambézia Province, Mozambique were shown nine choice cards and asked to select one of two hypothetical health facilities, each with six varying characteristics related to the delivery of HIV services for long term treatment. Mixed logit models were used to estimate the influence of six health service attributes on choice of clinics.Results2,033 women participated in the study (response rate 97.8% in Ethiopia and 94.7% in Mozambique). Among the various attributes of structure and content of lifelong ART services, the most important attributes identified in both countries were respectful provider attitude and ability to obtain non-HIV health services during HIV-related visits. Availability of counseling support services was also a driver of choice. Facility type, i.e., hospital versus health center, was substantially less important.ConclusionsEfforts to enhance retention in HIV care and treatment for pregnant women should focus on promoting respectful care by providers and integrating access to non-HIV health services in the same visit, as well as continuing to strengthen counseling.

Did PEPFAR investments result in health system strengthening? A retrospective longitudinal study measuring non-HIV health service utilization at the district level.

Objectives PEPFAR’s initial rapid scale-up approach was largely a vertical effort focused fairly exclusively on AIDS. The purpose of our research was to identify spill-over health system effects, if any, of investments intended to stem the HIV epidemic over a 6-year period with evidence from Uganda. The test of whether there were health system expansions (aside from direct HIV programming) was evidence of increases in utilization of non-HIV services—such as outpatient visits, in-facility births or immunizations—that could be associated with varying levels of PEPFAR investments at the district level.Methods Uganda’s Health Management Information System article-based records were available from mid-2005 onwards. We visited all 112 District Health offices to collect routine monthly reports (which contain data aggregated from monthly facility reports) and annual reports (which contain data aggregated from annual facility reports). Counts of individuals on anti-retroviral therapy (ART) at year-end served as our primary predictor variable. We grouped district-months into tertiles of high, medium or low PEPFAR investment based on their total reported number of patients on ART at the end of the year. We generated incidence-rate ratios, interpreted as the relative rate of the outcome measure in relation to the lowest investment PEPFAR tertile, holding constant control variables in the model.Results We found PEPFAR investment overall was associated with small declines in service volumes in several key areas of non-HIV care (outpatient care for young children, TB tests and in-facility deliveries), after adjusting for sanitation, elementary education and HIV prevalence. For example, districts with medium and high ART investment had 11% fewer outpatient visits for children aged 4 and younger compared with low investment districts, incidence rate ratio (IRR) of 0.89 for high investment compared with low (95% CI, 0.85–0.94) and IRR of 0.93 for medium compared with low (0.90–0.96). Similarly, 22% fewer TB sputum tests were performed in high investment districts compared with low investment, [IRR 0.78 (0.72–0.85)] and 13% fewer in medium compared with low, [IRR 0.88 (0.83–0.94)]. Districts with medium and high ART investment had 5% fewer in-facility deliveries compared with low investment districts [IRR 0.95 for high compared with low, (91–1.00) and 0.96 for medium compared with low (0.93–0.99)]. Although not statistically significant, the rate of maternal deaths in high investment district-months was 13% lower than observed in low investment districts.Conclusions This study sought to understand whether PEPFAR, as a vertical programme, may have had a spill-over effect on the health system generally, as measured by utilization. Our conclusion is that it did not, at least not in Uganda.

Increased utilisation of PEPFAR-supported laboratory services by non-HIV patents in Tanzania.

BackgroundIt is unknown to what extent the non-HIV population utilises laboratories supported by the President’s Emergency Plan for AIDS Relief (PEPFAR).ObjectivesWe aimed to describe the number and proportion of laboratory tests performed in 2009 and 2011 for patients referred from HIV and non-HIV services (NHSs) in a convenience sample collected from 127 laboratories supported by PEPFAR in Tanzania. We then compared changes in the proportions of tests performed for patients referred from NHSs in 2009 vs 2011.MethodsHaematology, chemistry, tuberculosis and syphilis test data were collected from available laboratory registers. Referral sources, including HIV services, NHSs, or lack of a documented referral source, were recorded. A generalised linear mixed model reported the odds that a test was from a NHS.ResultsA total of 94 132 tests from 94 laboratories in 2009 and 157 343 tests from 101 laboratories in 2011 were recorded. Half of all tests lacked a documented referral source. Tests from NHSs constituted 42% (66 084) of all tests in 2011, compared with 31% (29 181) in 2009. A test in 2011 was twice as likely to have been referred from a NHS as in 2009 (adjusted odds ratio: 2.0 [95% confidence interval: 2.0–2.1]).ConclusionBetween 2009 and 2011, the number and proportion of tests from NHSs increased across all types of test. This finding may reflect increased documentation of NHS referrals or that the laboratory scale-up originally intended to service the HIV-positive population in Tanzania may be associated with a ‘spillover effect’ amongst the general population.