Barriers and facilitators to linkage to ART in primary care: a qualitative study of patients and providers in Blantyre,Malawi

Introduction

Linkage from HIV testing and counselling (HTC) to initiation of antiretroviral therapy (ART) is suboptimal in many national programmes in sub-Saharan Africa, leading to delayed initiation of ART and increased risk of death. Reasons for failure of linkage are poorly understood.

Methods

Semi-structured qualitative interviews were undertaken with health providers and HIV-positive primary care patients as part of a prospective cohort study at primary health centres in Blantyre, Malawi. Patients successful and unsuccessful in linking to ART were included.

Results

Progression through the HIV care pathway was strongly influenced by socio-cultural norms, particularly around the perceived need to regain respect lost during a period of visibly declining health. Capacity to call upon the support of networks of families, friends and employers was a key determinant of successful progression. Over-busy clinics, non-functioning laboratories and unsuitable tools used for ART eligibility assessment (WHO clinical staging system and centralized CD4 count measurement) were important health systems determinants of drop-out.

Conclusions

Key interventions that could rapidly improve linkage include guarantee of same-day, same-clinic ART eligibility assessments; utilization of the support offered by peer-groups and community health workers; and integration of HTC and ART programmes.     

Linkage to care following a home-based HIV counselling and testing intervention in rural South Africa

Introduction

Efforts to increase awareness of HIV status have led to growing interest in community-based models of HIV testing. Maximizing the benefits of such programmes requires timely linkage to care and treatment. Thus, an understanding of linkage and its potential barriers is imperative for scale-up.

Methods

This study was conducted in rural South Africa. HIV-positive clients (n=492) identified through home-based HIV counselling and testing (HBHCT) were followed up to assess linkage to care, defined as obtaining a CD4 count. Among 359 eligible clients, we calculated the proportion that linked to care within three months. For 226 clients with available data, we calculated the median CD4. To determine factors associated with the rate of linkage, Cox regression was performed on a subsample of 196 clients with additional data on socio-demographic factors and personal characteristics.

Results

We found that 62.1% (95% CI: 55.7 to 68.5%) of clients from the primary sample (n=359) linked to care within three months of HBHCT. Among those who linked, the median CD4 count was 341 cells/mm³ (interquartile range [IQR] 224 to 542 cells/mm³). In the subsample of 196 clients, factors predictive of increased linkage included the following: believing that drugs/supplies were available at the health facility (adjusted hazard ratio [aHR] 1.78; 95% CI: 1.07 to 2.96); experiencing three or more depression symptoms (aHR 2.09; 95% CI: 1.24 to 3.53); being a caregiver for four or more people (aHR 1.93; 95% CI: 1.07 to 3.47); and knowing someone who died of HIV/AIDS (aHR 1.68; 95% CI: 1.13 to 2.49). Factors predictive of decreased linkage included the following: younger age – 15 to 24 years (aHR 0.50; 95% CI: 0.28 to 0.91); living with two or more adults (aHR 0.52; 95% CI: 0.35 to 0.77); not believing or being unsure about the test results (aHR 0.48; 95% CI: 0.30 to 0.77); difficulty finding time to seek health care (aHR 0.40; 95% CI: 0.24 to 0.67); believing that antiretroviral treatment can make you sick (aHR 0.56; 95% CI: 0.35 to 0.89); and drinking alcohol (aHR 0.52; 95% CI: 0.34 to 0.80).

Conclusions

The findings highlight barriers to linkage following an increasingly popular model of HIV testing. Further, they draw attention to ways in which practical interventions and health education strategies could be used to improve linkage to care.     

Missed opportunities of inclusion in a cohort of HIV-infected children to initiate antiretroviral treatment before the age of two in West Africa, 2011 to 2013

Introduction

The World Health Organization (WHO) 2010 guidelines recommended to treat all HIV-infected children less than two years of age. We described the inclusion process and its correlates of HIV-infected children initiated on early antiretroviral therapy (EART) at less than two years of age in Abidjan, Côte d''Ivoire, and Ouagadougou, Burkina Faso.

Methods

All children with HIV-1 infection confirmed with a DNA PCR test of a blood sample, aged less than two years, living at a distance less than two hours from the centres and whose parents (or mother if she was the only legal guardian or the legal caregiver if parents were not alive) agreed to participate in the MONOD ANRS 12206 project were included in a cohort to receive EART based on lopinavir/r. We used logistic regression to identify correlates of inclusion.

Results

Among the 217 children screened and referred to the MONOD centres, 161 (74%) were included and initiated on EART. The main reasons of non-inclusion were fear of father''s refusal (48%), mortality (24%), false-positive HIV infection test (16%) and other ineligibility reasons (12%). Having previously disclosed the child''s and mother''s HIV status to the father (adjusted odds ratio (aOR): 3.20; 95% confidence interval (95% CI): 1.55 to 6.69) and being older than 12 months (aOR: 2.05; 95% CI: 1.02 to 4.12) were correlates of EART initiation. At EART initiation, the median age was 13.5 months, 70% had reached WHO Stage 3/4 and 57% had a severe immune deficiency.

Conclusions

Fear of stigmatization by the father and early competing mortality were the major reasons for missed opportunities of EART initiation. There is an urgent need to involve fathers in the care of their HIV-exposed children and to promote early infant diagnosis to improve their future access to EART and survival.     

上海市社区医护人员骨质疏松症社区管理实施影响因素的路径分析

目的评估上海市社区医护人员骨质疏松症社区管理实施现状,采用社会生态学理论探讨社区医护人员骨质疏松症社区管理实施的相关影响因素,通过路径分析探究影响因素间的相互作用路径。方法采用方便抽样的方法在上海市20家社区卫生服务中心各抽取42名医护人员共840人进行问卷调查,了解被调查的医护人员骨质疏松症社区管理实施现状及相关影响因素,采用Logistic回归和路径分析对相关影响因素进行分析。结果多因素的Logistic回归结果显示,骨质疏松症危险因素识别技巧(ORm=1.66,95%CI=1.14～2.42)、自我效能(ORm=8.39,95%CI=5.90～11.92)、骨质疏松症社区管理的社区医院环境支持(ORm=1.65,95%CI=1.19～2.29)均能促进社区医护人员骨质疏松症社区管理工作的实施。路径分析结果表明自我效能通过直接效应作用于社区医护人员骨质疏松症社区管理的实施(因子载荷=0.60,P0.001),而社区环境支持(因子载荷=0.11,P0.001)和危险因素识别技巧(因子载荷=0.08,P0.001)可直接也可通过自我效能的中介效应来作用于社区医护人员骨质疏松症社区管理的实施。结论经路径分析发现,社区医护人员骨质疏松症的社区管理的实施是个人、人际及社区三层面因素相互作用影响的,提示在进行干预时,应结合个人与周围环境多层面进行有针对性的干预。     

HIV prevention and care services for female sex workers: efficacy of a targeted community-based intervention in Burkina Faso

Introduction

Although interventions to control HIV among high-risk groups such as female sex workers (FSW) are highly recommended in Africa, the contents and efficacy of these interventions are unclear. We therefore designed a comprehensive dedicated intervention targeting young FSW and assessed its impact on HIV incidence in Burkina Faso.

Methods

Between September 2009 and September 2011 we conducted a prospective, interventional cohort study of FSW aged 18 to 25 years in Ouagadougou, with quarterly follow-up for a maximum of 21 months. The intervention combined prevention and care within the same setting, consisting of peer-led education sessions, psychological support, sexually transmitted infections and HIV care, general routine health care and reproductive health services. At each visit, behavioural characteristics were collected and HIV, HSV-2 and pregnancy were tested. We compared the cohort HIV incidence with a modelled expected incidence in the study population in the absence of intervention, using data collected at the same time from FSW clients.

Results

The 321 HIV-uninfected FSW enrolled in the cohort completed 409 person-years of follow-up. No participant seroconverted for HIV during the study (0/409 person-years), whereas the expected modelled number of HIV infections were 5.05/409 person-years (95% CI, 5.01–5.08) or 1.23 infections per 100 person-years (p=0.005). This null incidence was related to a reduction in the number of regular partners and regular clients, and by an increase in consistent condom use with casual clients (adjusted odds ratio (aOR)=2.19; 95% CI, 1.16–4.14, p=0.01) and with regular clients (aOR=2.18; 95% CI, 1.26–3.76, p=0.005).

Conclusions

Combining peer-based prevention and care within the same setting markedly reduced the HIV incidence among young FSW in Burkina Faso, through reduced risky behaviours.     

健康教育与模拟训练预防社区儿童意外伤害研究

目的 探讨预防社区儿童意外伤害的健康教育与模拟训练方法,提高家长的防护意识、知识及技能,降低儿童意外伤害的发生率.方法 对40名儿童及其家长按0～3岁组,4～5岁组分组进行健康教育,包括专题讲座,实际案例、录像、动画片等;模拟训练包括各种急救法的训练,模拟游戏等.结果 干预前后儿童家长意外伤害知识与技能掌握率、社区儿童...     

Mental health and initiation of antiretroviral treatment at enrolment into HIV care in Cameroon under a national “treat all” policy: a cross‐sectional analysis

IntroductionRapid antiretroviral treatment (ART) initiation reduces time from HIV infection to viral suppression, decreasing HIV transmission risk. Mental health symptoms may influence timing of ART initiation. This study estimated the prevalence of ART initiation at enrolment into HIV care and the relationship between mental health and ART initiation at enrolment into HIV care.MethodsWe conducted interviews with 426 individuals initiating HIV care in Cameroon between June 2019 and March 2020 to estimate the association between mental health and timing of ART initiation. Depression (Patient Health Questionnaire‐9; cut‐point 10), anxiety (Generalized Anxiety Disorder‐7; cut‐point 10), post‐traumatic stress disorder (PTSD) (PTSD Checklist for DSM‐5; cut‐point 31) and harmful alcohol use (Alcohol Use Disorders Identification Test; cut‐point 16) were dichotomized to represent those with and without each exposure at first HIV care appointment. Date of ART initiation (date ART prescribed) was ascertained from medical records. Separate multivariable log‐binomial regression models were used to estimate the association between mental health exposures and ART initiation at enrolment into care.Results and discussionOverall, 87% initiated ART at enrolment into HIV care. Approximately 20% reported depressive symptoms, 15% reported PTSD symptoms, 12% reported anxiety symptoms and 13% reported harmful alcohol use. In multivariable analyses, individuals with moderate to severe depressive symptoms had 1.7 (95% confidence interval [CI] 1.1, 2.7) times the prevalence of not initiating ART at enrolment into HIV care compared to those with no or mild depressive symptoms. Those with symptoms of PTSD, compared to those without, had 1.9 (95% CI 1.2, 2.9) times the prevalence of not initiating ART at enrolment into HIV care. Symptoms of anxiety or harmful drinking were not associated with ART initiation at enrolment into HIV care in multivariable models.ConclusionsSymptoms of depression and PTSD were associated with lower prevalence of ART initiation at enrolment into HIV care among this sample of individuals initiating HIV care in Cameroon under a “treat all” policy. Research should examine barriers to timely ART initiation, whether incorporating mental health services into HIV care improves timely ART initiation, and whether untreated symptoms of depression and PTSD drive suboptimal HIV care outcomes.     

Evaluating the feasibility and uptake of a community‐led HIV testing and multi‐disease health campaign in rural Uganda

Introduction: Multi‐disease community health campaigns can be effective for population‐wide HIV testing in a research setting (SEARCH: NCT01864603). We sought to evaluate feasibility and uptake of a community‐led health campaign (CLHC) planned and implemented by village leaders and local clinic workers in Uganda. Methods: Over five months in 2014, locally elected village leaders and Ministry of Health (MoH) clinic staff in a rural parish in Uganda planned a census followed by a CLHC, after training by two SEARCH trial consultants and by leaders from a neighbouring parish that had previously participated in a SEARCH health campaign. We defined feasibility as: (1) elected leaders’ participation in training and implementation of pre‐campaign census and mobilization activities; (2) implementation of all campaign activities by MoH‐funded, local clinic staff; and (3) community participation in the campaign, including point‐of‐care screening for HIV, malaria, hypertension and diabetes, and same‐day referral for male circumcision and family planning (FP). Costing of all salaries and supplies was conducted. Results: Elected leaders from all eight villages in the parish participated in CLHC training. They and local clinic staff met monthly to select and plan CLHC services. Village leaders then leveraged existing volunteer health teams to perform a door‐to‐door census, enumerating 5,202 parish residents over 2 weeks. 2,753 (53%) residents participated in the 6‐day CLHC. Of 1,584 adult participants, 1,474 (93%) tested for HIV: 105/1,474 (7.1%) tested HIV positive. 27% (751/2,753) of participants reported fever and underwent malaria rapid diagnostic testing: 5.3% (40/751) tested positive. Among adults screened, 19% (271/1,452) were hypertensive, and 3% (18/637) had a random blood sugar >11.1 mmol/L. Of 805 men and boys (>10 years), 91 (11%) accepted same‐day clinic referral and underwent medical circumcision. Of 900 women offered same‐day long‐term FP referrals, 25 accepted. The CLHC cost, including census, mobilization and testing services, was $23,597 ($8.57/participant). C onclusions: Elected village leaders successfully planned and conducted a 6‐day multi‐disease health campaign with service provision by local clinic staff that reached over half of a rural Ugandan community. These data suggest it is feasible for local leaders and clinics to adopt a multi‐disease health campaign approach to scale‐up HIV testing in rural Africa.     

Acceptability of woman‐delivered HIV self‐testing to the male partner,and additional interventions: a qualitative study of antenatal care participants in Malawi

Introduction : In the era of ambitious HIV targets, novel HIV testing models are required for hard‐to‐reach groups such as men, who remain underserved by existing services. Pregnancy presents a unique opportunity for partners to test for HIV, as many pregnant women will attend antenatal care (ANC). We describe the views of pregnant women and their male partners on HIV self‐test kits that are woman‐delivered, alone or with an additional intervention. Methods : A formative qualitative study to inform the design of a multi‐arm multi‐stage cluster‐randomized trial, comprised of six focus group discussions and 20 in‐depth interviews, was conducted. ANC attendees were purposively sampled on the day of initial clinic visit, while men were recruited after obtaining their contact information from their female partners. Data were analysed using content analysis, and our interpretation is hypothetical as participants were not offered self‐test kits. Results : Providing HIV self‐test kits to pregnant women to deliver to their male partners was highly acceptable to both women and men. Men preferred this approach compared with standard facility‐based testing, as self‐testing fits into their lifestyles which were characterized by extreme day‐to‐day economic pressures, including the need to raise money for food for their household daily. Men and women emphasized the need for careful communication before and after collection of the self‐test kits in order to minimize the potential for intimate partner violence although physical violence was perceived as less likely to occur. Most men stated a preference to first self‐test alone, followed by testing as a couple. Regarding interventions for optimizing linkage following self‐testing, both men and women felt that a fixed financial incentive of approximately USD$2 would increase linkage. However, there were concerns that financial incentives of greater value may lead to multiple pregnancies and lack of child spacing. In this low‐income setting, a lottery incentive was considered overly disappointing for those who receive nothing. Phone call reminders were preferred to short messaging service. Conclusions : Woman‐delivered HIV self‐testing through ANC was acceptable to pregnant women and their male partners. Feedback on additional linkage enablers will be used to alter pre‐planned trial arms.