Rural HIV Clinic Research Articles

HIV-1 virologic failure and acquired drug resistance among first-line antiretroviral experienced adults at a rural HIV clinic in coastal Kenya: a cross-sectional study

BackgroundAn increasing number of people on antiretroviral therapy (ART) in sub-Saharan Africa has led to declines in HIV related morbidity and mortality. However, virologic failure (VF) and acquired drug resistance (ADR) may negatively affect these gains. This study describes the prevalence and correlates of HIV-1 VF and ADR among first-line ART experienced adults at a rural HIV clinic in Coastal Kenya.MethodsHIV-infected adults on first-line ART for ≥6 months were cross-sectionally recruited between November 2008 and March 2011. The primary outcome was VF, defined as a one-off plasma viral load of ≥400 copies/ml. The secondary outcome was ADR, defined as the presence of resistance associated mutations. Logistic regression and Fishers exact test were used to describe correlates of VF and ADR respectively.ResultsOf the 232 eligible participants on ART over a median duration of 13.9 months, 57 (24.6% [95% CI: 19.2 – 30.6]) had VF. Fifty-five viraemic samples were successfully amplified and sequenced. Of these, 29 (52.7% [95% CI: 38.8 – 66.3]) had at least one ADR, with 25 samples having dual-class resistance mutations. The most prevalent ADR mutations were the M184V (n = 24), K103N/S (n = 14) and Y181C/Y/I/V (n = 8). Twenty-six of the 55 successfully amplified viraemic samples (47.3%) did not have any detectable resistance mutation. Younger age (15–34 vs. ≥35 years: adjusted odd ratios [95% CI], p-value: 0.3 [0.1–0.6], p = 0.002) and unsatisfactory adherence (<95% vs. ≥95%: 3.0 [1.5–6.5], p = 0.003) were strong correlates of VF. Younger age, unsatisfactory adherence and high viral load were also strong correlates of ADR.ConclusionsHigh levels of VF and ADR were observed in younger patients and those with unsatisfactory adherence. Youth-friendly ART initiatives and strengthened adherence support should be prioritized in this Coastal Kenyan setting. To prevent unnecessary/premature switches, targeted HIV drug resistance testing for patients with confirmed VF should be considered.

Impact of family planning health talks by lay health workers on contraceptive knowledge and attitudes among HIV-infected patients in rural Kenya

ObjectiveTo determine if a health talk on family planning (FP) by community clinic health assistants (CCHAs) will improve knowledge, attitudes and behavioral intentions about contraception in HIV-infected individuals. MethodsA 15-min FP health talk was given by CCHAs in six rural HIV clinics to a sample of 49 HIV-infected men and women. Effects of the health talk were assessed through a questionnaire administered before the health talk and after completion of the participant's clinic visit. ResultsFollowing the health talk, there was a significant increase in knowledge about contraceptives (p<.0001), side-effects (p<.0001), and method-specific knowledge about IUCDs (p<.001), implants (p<.0001), and injectables (p<.05). Out of 31 women and 18 men enrolled, 14 (45%) women and 6 (33%) men intended to try a new contraceptive. Participant attitudes toward FP were high before and after the health talk (median 4 of 4). ConclusionA health talk delivered by CCHAs can increase knowledge of contraception and promote the intention to try new more effective contraception among HIV-infected individuals. Practice implicationsFP health talks administered by lay-health providers to HIV-infected individuals as they wait for HIV services can influence FP knowledge and intention to use FP.

B112 An Evaluation of Distance and its Impact on Long-term Follow up Outcomes in a Rural HIV Clinic in Northern Haiti

B112 An Evaluation of Distance and its Impact on Long-term Follow up Outcomes in a Rural HIV Clinic in Northern Haiti

Low Prevalence of Transmitted HIV Type 1 Drug Resistance Among Antiretroviral-Naive Adults in a Rural HIV Clinic in Kenya

Low levels of HIV-1 transmitted drug resistance (TDR) have previously been reported from many parts of sub-Saharan Africa (sSA). However, recent data, mostly from urban settings, suggest an increase in the prevalence of HIV-1 TDR. Our objective was to determine the prevalence of TDR mutations among HIV-1-infected, antiretroviral (ARV)-naive adults enrolling for care in a rural HIV clinic in Kenya. Two cross-sectional studies were carried out between July 2008 and June 2010. Plasma samples from ARV-naive adults (>15 years old) at the time of registering for care after HIV diagnosis and before starting ARVs were used. A portion of the pol subgenomic region of the virus containing the protease and part of the reverse transcriptase genes was amplified and sequenced. TDR mutations were identified and interpreted using the Stanford HIV drug resistance database and the WHO list for surveillance of drug resistance strains. Overall, samples from 182 ARV-naive adults [mean age (95% CI): 34.9 (33.3-36.4) years] were successfully amplified and sequenced. Two TDR mutations to nucleoside reverse transcriptase inhibitors [n=1 (T215D)] and protease inhibitors [n=1 (M46L)] were identified, giving an overall TDR prevalence of 1.1% (95% CI: 0.1-3.9). Despite reports of an increase in the prevalence of HIV-1 TDR in some urban settings in sSA, we report a prevalence of HIV-1 TDR of less than 5% at a rural HIV clinic in coastal Kenya. Continued broader surveillance is needed to monitor the extent of TDR in sSA.

Clinical and social determinants of diarrhoeal disease in a rural HIV/AIDS clinic, South Africa: a case-control study.

Diarrhoeal diseases are a common cause of morbidity and are associated with mortality in HIV-infected populations. Little is known about the contribution of clinical and socio-environmental factors to the risk of diarrhoea in these populations in rural sub-Saharan Africa. We conducted a case-control study of people attending a rural HIV clinic with an episode of diarrhoea in Bushbuckridge, South Africa. Cases were defined as HIV-positive adults with symptoms of diarrhoea before or after initiation of antiretroviral therapy (ART). Controls without diarrhoea were randomly selected from clinic attendees. Structured questionnaires and case-file reviews were undertaken to describe clinical and socioenvironmental risk factors. We recruited 103 cases of diarrhoea from 121 patients meeting case definitions. Cases were more likely to be women (P = 0.013), aged over 45 years (P = 0.002), divorced or separated (P = 0.006), have limited formal education (P = 0.003), have inadequate access to sanitation facilities (P = 0.045), have water access limited to less than three days per week (P = 0.032) and not yet initiated on ART (P < 0.001). In multivariate analysis, diarrhoea remained associated with female gender (adjusted odds ratio [aOR]: 2.02, 95% CI 1.10-3.73), older age (aOR: 6.31, 95% CI 1.50-26.50), limited access to water (aOR: 2.66, 95% CI 1.32-5.35) and pre-ART status (aOR: 5.87, 95% CI 3.05-11.27). Clinical and socio-environmental factors are associated with occurrence of diarrhoeal disease among rural HIV patients in South Africa. Further intervention research is urgently needed, combining community- and clinic-based approaches, to improve access to water, sanitation and ART for rural areas with high HIV prevalence, along with structural interventions to address gender inequities.

Concurrent use of complementary and alternative medicine with antiretroviral therapy reduces adherence to HIV medications

Antiretroviral therapy requires strict adherence to ensure therapeutic success. Concurrent use of complementary and alternative medicine (CAM) could alter the adherence to and thereby effectiveness of antiretroviral drugs. This study examined the association of CAM use with adherence to antiretroviral therapy (ART) and CD4 count. The study was conducted in two HIV clinics: one in a semi-urban, the other in a rural area. Adherence to ART was assessed using the Morisky Medication Adherence Scale (MMAS). Data on type of CAM used and MMAS adherence were collected by patient interview and demographic; clinical data were collected from hospital records. Altogether 212 HIV patients participated in the exit study conducted over 3 months. Almost half (47.9%) used CAM concurrently with antiretroviral drugs. Dietary supplements (40.3%), healing systems (36.5%) and exercise (23.2%) were mainly used. The use of CAM significantly lowered adherence to ART (89.4% in non-CAM users versus 82.5% in CAM users, P = 0.01). Improvement in CD4 count was less in patients using CAM compared to non-CAM users although the difference was not statistically significant (310.5 ± 294.0 cells/L in CAM users versus 224.5 ± 220.0 cells/L in non-CAM users, P = 0.13). Patients attending the rural HIV clinic were more likely to use CAM compared to patients attending semi-urban hospital (χ(2) test = 7.0; P < 0.01). Use of CAM could lower adherence to antiretroviral therapy. There is need to develop protocol which could help in monitoring CAM use in HIV patients especially those from rural settings.

HIV-Infected Children in Rural Zambia Achieve Good Immunologic and Virologic Outcomes Two Years after Initiating Antiretroviral Therapy

BackgroundMany HIV-infected children in sub-Saharan Africa reside in rural areas, yet most research on treatment outcomes has been conducted in urban centers. Rural clinics and residents may face unique barriers to care and treatment.MethodsA prospective cohort study of HIV-infected children was conducted between September 2007 and September 2010 at the rural HIV clinic in Macha, Zambia. HIV-infected children younger than 16 years of age at study enrollment who received antiretroviral therapy (ART) during the study were eligible. Treatment outcomes during the first two years of ART, including mortality, immunologic status, and virologic suppression, were assessed and risk factors for mortality and virologic suppression were evaluated.ResultsA total of 69 children entered the study receiving ART and 198 initiated ART after study enrollment. The cumulative probabilities of death among children starting ART after study enrollment were 9.0% and 14.4% at 6 and 24 months after ART initiation. Younger age, higher viral load, lower CD4+ T-cell percentage and lower weight-for-age z-scores at ART initiation were associated with higher risk of mortality. The mean CD4+ T-cell percentage increased from 16.3% at treatment initiation to 29.3% and 35.0% at 6 and 24 months. The proportion of children with undetectable viral load increased to 88.5% and 77.8% at 6 and 24 months. Children with longer travel times (≥5 hours) and those taking nevirapine at ART initiation, as well as children who were non-adherent, were less likely to achieve virologic suppression after 6 months of ART.ConclusionsHIV-infected children receiving treatment in a rural clinic experienced sustained immunologic and virologic improvements. Children with longer travel times were less likely to achieve virologic suppression, supporting the need for decentralized models of ART delivery.

Decreased sexual risk behavior in the era of HAART among HIV-infected urban and rural South Africans attending primary care clinics.

In light of increasing access to HAART in sub-Saharan Africa, we conducted a longitudinal study to assess the impact of HAART on sexual risk behaviors among HIV-infected South Africans in urban and rural primary care clinics. Prospective observational cohort. We conducted a cohort study at rural and urban primary care HIV clinics in South Africa consisting of 1544 men and 4719 women enrolled from 2003 to 2010, representing 19703 clinic visits. The primary outcomes were being sexually active, unprotected sex, and more than one sex partner and were evaluated at 6 monthly intervals. Generalized estimated equations assessed the impact of HAART on sexual risk behaviors. Among 6263 HIV-infected men and women, over a third (37.2%) initiated HAART during study follow-up. In comparison to pre-HAART follow-up, visits while receiving HAART were associated with a decrease in those reporting being sexually active [adjusted odds ratio: 0.86 (95% confidence interval: 0.78-0.95)]. Unprotected sex and having more than one sex partner were reduced at visits following HAART initiation compared to pre-HAART visits [adjusted odds ratio: 0.40 (95% confidence interval: 0.34-0.46) and adjusted odds ratio: 0.20 (95% confidence interval: 0.14-0.29), respectively]. Sexual risk behavior significantly decreased following HAART initiation among HIV-infected South African men and women in primary care programs. The further expansion of antiretroviral treatment programs could enhance HIV prevention efforts in Africa.

A Qualitative Analysis of the Economic Impact of HIV and Antiretroviral Therapy on Individuals and Households in Uganda

Despite the acceleration of antiretroviral therapy (ART) scale-up in sub-Saharan Africa, little is known about the social and economic effects of ART on individuals and households. In January 2008, we conducted semistructured interviews with 24 adult ART clients attending urban and rural HIV clinics operated by Joint Clinical Research Center in Uganda. Using content analysis we explored changes in physical health, work activity and asset management from before HIV to after ART. Twenty-one (88%) participants were working prior to HIV (mostly microenterprises and subsistence farming), of whom 18 had to stop work at least temporarily after onset of HIV. After ART, 20 (83% of the sample) were engaged in some type of work, but for many it was not at the same level as before HIV. Also, most that previously had salaried employment were unable to return to the formal labor market. Two thirds of the sample reported having to sell off at least some of their land, capital, or household property after HIV, and few were able to buy it back after ART. A majority (67%) reported that economic support from family was instrumental after the onset of HIV, and for 38% this support continued to be necessary after ART. These findings highlight that while ART helps people to regain a capacity to work, other economic supports are needed to enable individuals and households to reestablish their livelihoods, especially in resource-constrained settings.

Survey of Patient and Clinician Attitudes on Adherence in a Rural HIV Clinic

Adherence is critical to the success of antiretroviral therapy, with near perfect medication taking required for optimal results. Many factors may affect a patient's ability to adhere to antiretroviral therapy, including complexity of the regimen and adverse effects from medications. Previous research showed that some disparity may exist between clinicians' and patients' attitudes regarding characteristics of a regimen that are likely to affect adherence. The present survey was conducted in a rural HIV clinic and confirmed that similar differences were present in clinician and patient perceptions of adherence barriers. The patient population noted side effects and complexity of schedule as most likely to affect adherence, illustrating the need for thorough discussion of new regimens and involvement of the patient in treatment decisions.