Homelessness as a structural barrier to effective antiretroviral therapy among HIV-seropositive illicit drug users in a Canadian setting

Despite the advent of effective antiretroviral therapy (ART), HIV-seropositive injection drug users (IDU) continue to suffer from elevated levels of morbidity and mortality. Evidence is needed to identify social- and structural-level barriers to effective ART. We investigated the impact of homelessness on plasma HIV RNA response among illicit drug users initiating ART in a setting with free and universal access to HIV care. We accessed data from a long-running prospective cohort of community-recruited IDU linked to comprehensive HIV clinical monitoring and ART dispensation records. Using Cox proportional hazards with recurrent events modeling, we estimated the independent effect of homelessness on time to plasma HIV viral load suppression. Between May 1996 and September 2009, 247 antiretroviral na?ve individuals initiated ART and contributed 1755 person-years of follow-up. Among these individuals, the incidence density of plasma HIV RNA suppression less than 500 copies/mm(3) was 56.7 (95% confidence interval [CI]: 46.9-66.0) per 100 person-years. In unadjusted analyses, homelessness was strongly associated with lower rates suppression (hazard ratio = 0.56, 95% CI: 0.40-0.78, p = 0.001), however, after adjustment for adherence this association was no longer significant (adjusted hazard ratio = 0.79, 95% CI: 0.56-1.11, p = 0.177). Homelessness poses a significant structural barrier to effective HIV treatment. However, since this relationship appears to be mediated by lower levels of ART adherence, interventions to improve adherence among members of this vulnerable population are needed.     

Methadone maintenance therapy promotes initiation of antiretroviral therapy among injection drug users

Aims Despite proven benefits of antiretroviral therapy (ART), many human immunodeficiency virus (HIV)‐infected injection drug users (IDU) do not access treatment even in settings with free health care. We examined whether methadone maintenance therapy (MMT) increased initiation and adherence to ART among an IDU population with free health care. Design We examined prospectively a cohort of opioid‐using antiretroviral‐naive HIV‐infected IDU and investigated factors associated with initiation of antiretroviral therapy as well as subsequent adherence. Factors associated independently with time to first initiation of antiretroviral therapy were modelled using Cox proportional hazards regression. Findings Between May 1996 and April 2008, 231 antiretroviral‐naive HIV‐infected opioid‐using IDU were enrolled, among whom 152 (65.8%) initiated ART, for an incidence density of 30.5 [95% confidence interval (CI): 25.9–35.6] per 100 person‐years. After adjustment for time‐updated clinical characteristics and other potential confounders, use of MMT was associated independently with more rapid uptake of antiretroviral therapy [relative hazard = 1.62 (95% CI: 1.15–2.28); P = 0.006]. Those prescribed methadone also had higher rates of ART adherence after first antiretroviral initiation [odds ratio = 1.49 (95% CI: 1.07–2.08); P = 0.019]. Conclusion These results demonstrate that MMT contributes to more rapid initiation and subsequent adherence to ART among opioid‐using HIV‐infected IDU. Addressing international barriers to the use and availability of methadone may increase dramatically uptake of HIV treatment among this population.     

Effects of Counselling on Adherence to Antiretroviral Treatment Among People with HIV in Estonia: A Randomized Controlled Trial

To assess the efficacy of an education- and strengths-based counselling programme to promote antiretroviral therapy (ART) adherence in a cohort of HIV-infected individuals with high prevalence of injection drug use in Estonia. Parallel-group randomized (1:1) controlled trial (RCT). Adults receiving ART in two clinics were followed for 12 months. The trial compared: (i) an intervention (three sessions) incorporated into routine clinic visits, providing education about HIV, ART, the role of adherence, and tailoring regimen to daily routines using problem-solving skills to address adherence barriers versus (ii) usual care (control). Primary and secondary outcomes were self-reported ART adherence (3-day recall) and viral load (respectively). 519 patients were randomized and 82% completed the study. Recent optimal ART adherence (3-day recall ≥95%) was reported by 75.6% in the intervention group and 72.9% of controls at baseline and 76.7% and 67.5%, respectively, at 12 months (RR 1.14, 95% CI 1.00–1.28; adjusted RR 1.13, 95% CI 1.00–1.27). There was no difference in the proportion of patients with undetectable viral load. At 12 months the intervention group reported significantly higher perceptions of ART necessity versus ART concerns [mean ART necessity-concerns differential: intervention group 1.32 (SD 1.22) vs control group 1.08 (SD 1.12); p = 0.048]. All-cause mortality among study participants was 27.7 per 1000 person years (95% CI 15.6–44.8). A brief, clinic-based adherence intervention alone may assist with adherence but lacks impact on viral load at 12 months.     

Operationalizing treatment as prevention in los angeles county: antiretroviral therapy use and factors associated with unsuppressed viral load in the ryan white system of care

Abstract Despite extensive prevention efforts, an estimated 21% of individuals with HIV/AIDS in the United States are unaware of their status, placing them at greater risk for spreading the virus to others. HIV treatment as prevention (TasP) is rapidly becoming an important public health strategy to reduce HIV transmission at the population level. Data for this study were collected on a sample of 11,397 HIV-positive individuals in the Ryan White system, a publicly funded system of care for HIV-positive individuals in Los Angeles County who are uninsured, in 2009 to examine two components of TasP: baseline rates and factors associated with antiretroviral therapy (ART) use and viral load (VL) suppression in a publicly funded system of care. ART coverage among our sample was 90%. In multivariate analyses, those with a higher odds of having unsuppressed VL included: females compared to males (adjusted odds ratio [AOR]=1.25; 95% confidence interval [CI]=1.06, 1.47); African Americans compared to whites (AOR=1.42; 95% CI=1.24, 1.62); men who have sex with men compared to heterosexuals (AOR=1.15; 95% CI=1.00, 1.32); recent substance abusers compared to nonsubstance abusers (AOR=1.35; 95% CI=1.17, 1.55); those recently incarcerated or ever incarcerated compared to those never incarcerated (AOR=1.37; 95% CI=1.15, 1.63; and AOR=1.28; 95% CI=1.09, 1.50); and those retained in care compared to those not retained in care (AOR=1.98; 95% CI=1.76, 2.22). Understanding the key sociodemographic, geographic and behavioral factors associated with ART use as well as HIV VL suppression will be useful for informing the development and deployment of targeted programming and policies that may further enhance the implementation of the TasP approach in communities across the United States.     

Improved virological suppression in children on antiretroviral treatment receiving community-based adherence support: A multicentre cohort study from South Africa

Adherence to antiretroviral treatment (ART) is a challenge in childhood, and children on ART have reduced virological suppression compared to adults. This study evaluated the effect of community-based adherence support (CBAS) on virological outcomes amongst children receiving ART in four South African provinces. Patient Advocates are lay CBAS workers who provide adherence and psychosocial support for patients, undertaking home visits to address household challenges affecting adherence. Patient Advocates provide counselling for children's carers regarding adherence and psychosocial problems. A multicentre cohort study using routinely collected data was conducted at 57 public ART sites including ART-naive children (<16 years) starting ART. Virological suppression until four years of ART was compared between children who received and did not receive CBAS. Analyses were by intention-to-treat, controlling for confounding using multivariable generalised estimating equations. A total of 4853 children were included, of whom 982 (20.2%) received CBAS. The median baseline age was 6.3 years and the baseline CD4 cell percentage was 12.0%; both were equivalent between the two groups. CBAS children had more advanced baseline clinical disease (62.1% vs. 52.6% World Health Organisation stages III or IV; P < 0.0001). A total of 5908 viral load results were analysed. Virological suppression was 65.6% (95% confidence interval [CI]: 62.7–68.4%) vs. 55.5% (95% CI: 54.1–57.0%) in CBAS and non-CBAS children, respectively, at any time-point on treatment (P < 0.0001). In analyses controlling for baseline clinical, demographic, site-related variables and time on ART, children receiving CBAS were more likely to achieve virological suppression, adjusted odds ratio (aOR) 1.60 (95% CI: 1.35–1.89; P < 0.0001). The effect of CBAS increased in magnitude with increasing durations of ART, and CBAS particularly improved virological suppression in a higher-risk subgroup (children younger than two years, aOR 2.47 [95% CI: 1.59–3.84]). CBAS was associated with improved virological suppression in children receiving ART. Expanded implementation of this low-cost intervention should be considered in resource-poor settings.     

Adherence is not a barrier to successful antiretroviral therapy in South Africa

OBJECTIVE: To determine adherence of an indigent African HIV-infected cohort initiating antiretroviral therapy (ART); to identify predictors of incomplete adherence (< 95%) and virologic failure (> 400 HIV RNA copies/ml). DESIGN: Prospective monitoring of adherence in a poor HIV-positive cohort, attending a public sector hospital and receiving ART through phase III studies. METHODS: Adherence to ART was determined over 48 weeks by counting tablet-returns. Logistic regression models including age, WHO HIV stage, home language, socio-economic status, complexity and type of regimen were fitted to determine predictors of incomplete adherence and virologic failure at 48 weeks. RESULTS: 289 patients were recruited between January 1996 and May 2001. Median (mean) adherence of the cohort was 93.5% (87.2%). Three times daily dosing [risk ratio (RR), 3.07; 95% confidence interval (CI), 1.40-6.74], speaking English (RR, 0.41; 95% CI, 0.21-0.80) and age (RR, 0.97; 95% CI, 0.94-0.99) were independent predictors of incomplete adherence. Socio-economic status, sex and HIV stage did not predict adherence. Independent predictors of virologic failure included baseline viral load (RR, 2.57; 95% CI, 1.57-4.22) and three times daily dosing (RR, 2.64; 95% CI, 1.23-5.66), incomplete adherence (RR, 1.92; 95% CI, 1.10-3.57), age (RR, 0.96; 95% CI, 0.92-0.99) and dual nucleoside therapy (RR, 2.69; 95% CI, 1.17-6.15). CONCLUSION: The proportion of individuals achieving viral suppression matched results from the developing world. Speaking the same language as site staff and simplified dosing frequency were beneficial. Socio-economic status had no impact on adherence and should not be used as a limitation to ART access.     

Factors associated with nonadherence to antiretroviral therapy in HIV-positive smokers

Adherence to antiretroviral therapy (ART) has markedly improved HIV disease management, and significantly reduced HIV/AIDS-associated morbidity and mortality. Although recent studies suggest a relationship between smoking and suboptimal adherence to ART, a more in-depth understanding of this relationship is needed. We conducted a secondary analysis using data from a randomized controlled smoking cessation trial to investigate the association of nonadherence to ART with potential demographic, psychosocial (perceived stress and depression), and substance use (nicotine dependence, illicit drug use, and alcohol use) variables among persons living with HIV/AIDS (PLWHA) who smoke. The mean (standard deviation [SD]) age of participants (n=326) was 45.9 years old (SD=7.6). Additionally, the majority were male (72.1%), self-identified as black (76.7%), and reported sexual contact as the mode of HIV acquisition (70%). Unadjusted logistic regression analysis indicated that depression (odds ratio [OR]=1.02; 95% confidence interval [CI]=1.00, 1.04), illicit drug use (OR=2.39; 95% CI=1.51, 3.79) and alcohol use (OR=2.86; 95%CI=1.79, 4.57) were associated with nonadherence. Adjusted logistic regression analysis indicated that nicotine dependence (OR=1.13; 95% CI=1.02, 1.25), illicit drug use (OR=2.10; 95% CI=1.27, 3.49), alcohol use (OR=2.50; 95% CI=1.52, 4.12), and age (OR=1.04; 95% CI=1.00, 1.07) were associated with nonadherence. Nicotine dependence, illicit drug use, and alcohol use are potentially formidable barriers to ART adherence among PLWHA who smoke. Future efforts should investigate the complex relationships among these variables to improve adherence particularly among populations confronted with multifaceted health challenges.     

Residential Eviction and Risk of Detectable Plasma HIV-1 RNA Viral Load Among HIV-Positive People Who Use Drugs

We examined the relationship between residential eviction and exhibiting detectable plasma HIV-1 RNA viral load (VL) among a prospective cohort of antiretroviral therapy (ART)-exposed HIV-seropositive people who use illicit drugs (PWUD) in Vancouver, Canada. We used multivariable generalized estimating equations to estimate the effect of residential eviction on detectable VL and examine ART adherence as a mediating variable. Between June 2007 and May 2014, 705 ART-exposed participants were included in the study, among whom 500 (70.9 %) experienced at least one period of detectable VL. In a time-updated multivariable model, eviction independently increased the odds of detectable VL among those who were homeless [adjusted odds ratio (AOR) = 2.25; 95 % confidence interval (CI) 1.18–4.29] as well as not homeless (AOR = 1.76; 95 % CI 1.17–2.63) post eviction. The results of mediation analyses suggest that this association was mediated by incomplete ART adherence. These findings suggest the need for further development and evaluation of interventions to prevent evictions and promote ART adherence among PWUD facing eviction.     

The effectiveness of treatment supporter interventions in antiretroviral treatment adherence in sub-Saharan Africa: a systematic review and meta-Analysis

ABSTRACT

This systematic review and meta-analysis evaluated the effectiveness of treatment supporter interventions (TSI) in improving ART adherence and viral suppression among adults living with HIV (PLWH) in sub-Saharan Africa. This review included ten randomized controlled trials (RCT) and six cohort studies comparing treatment support interventions to the standard of care (SOC). Primary outcomes include pill count ART adherence and viral load suppression (VLS). Pooled relative risk ratios (PRR) with 95% confidence intervals were generated using random-effects models. Stratified analyses and meta-regressions were conducted to determine the effect of study type, follow-upperiod, and patient treatment supporters on ART adherence. Treatment supporters included partners, friends, family members, trained community health workers, and HIV positive peers. TSIs were associated with a 7.6% higher ART adherence compared to the SOC group (PRR = 1.076, [95% CI = 1.005, 1.151]). VLS was 5% higher in the treatment group compared to the SOC group (PRR = 1.05, [95% CI = 1.061, 1.207]). There was a significant, positive association between TSIs and VLS in community-based delivery settings but not in facility-based settings. TSIs were statistically significant for VLS in cohort study designs (RR = 1.073, [95% CI = 1.028, 1.121]) but not in RCTs. Findings suggest that TSIs critical in facilitating optimal ART adherence and VLS among PLWHs.     

Antiretroviral therapy (ART) adherence and correlates to nonadherence among people on ART in Estonia

There are little data on antiretroviral therapy (ART) adherence among patients in Eastern Europe, despite the high incidence of HIV infection and the growing number of HIV-infected individuals who are being prescribed ART. The aim of this study was to measure rates of adherence to ART and factors associated with nonadherence among patients receiving care at an outpatient HIV clinic in Estonia. The study was based on cross-sectional data from a convenience sample of 144 patients receiving outpatient HIV care. Data were obtained via interviewer-administered surveys and data abstraction from clinical records. Adherence was measured from a 3-day patient self-report. Among 144 participants (mean age 33.8 years), two-thirds (63%) had been infected with HIV through intravenous drug use. Most (74%) were co-infected with hepatitis C (HCV). Perfect adherence over the last 3 days was commonly reported (88% [95% CI 81–92%]) with nonperfect adherence associated with greater concerns about the potential adverse consequences of taking ART (adjusted odds ratio [AOR] 4.8, 95% CI 1.2–34.0) and average (versus good/very good) self-reported health status (AOR 4.7, 95% CI 1.2–31.4). Self-reported ART adherence in this sample of Estonian HIV-positive patients in clinical care was similar to rates observed in Western Europe and other developed countries. Results suggest that adherence education and support may be most helpful if they specifically target the development of positive beliefs, reduction of negative expectancies towards ART.     

Factors linked to transitions in adherence to antiretroviral therapy among HIV-infected illicit drug users in a Canadian setting

HIV-positive people who use illicit drugs typically achieve lower levels of adherence to antiretroviral therapy and experience higher rates of sub-optimal HIV/AIDS treatment outcomes. Given the dearth of longitudinal research into ART adherence dynamics, we sought to identify factors associated with transitioning into and out of optimal adherence to ART in a longitudinal study of HIV-infected people who use illicit drugs (PWUD) in a setting of universal no-cost HIV/AIDS treatment. Using data from a prospective cohort of community-recruited HIV-positive illicit drug users confidentially linked to comprehensive HIV/AIDS treatment records, we estimated longitudinal factors associated with losing or gaining ≥95% adherence in the previous six months using two generalized linear mixed-effects models. Among 703 HIV-infected ART-exposed PWUD, becoming non-adherent was associated with periods of homelessness (adjusted odds ratio [AOR] = 2.52, 95% confidence interval [95% CI]: 1.56–4.07), active injection drug use (AOR = 1.25, 95% CI: 1.01–1.56) and incarceration (AOR = 1.54, 95% CI: 1.10–2.17). Periods of sex work (AOR = 0.51, 95% CI: 0.34–0.75) and injection drug use (AOR = 0.62, 95% CI: 0.50–0.77) were barriers to becoming optimally adherent. Methadone maintenance therapy was associated with becoming optimally adherent (AOR = 1.87, 95% CI: 1.50–2.33) and was protective against becoming non-adherent (AOR = 0.52, 95% CI: 0.41–0.65). In conclusion, we identified several behavioural, social and structural factors that shape adherence patterns among PWUD. Our findings highlight the need to consider these contextual factors in interventions that support the effective delivery of ART to this population.     

A community-based study of barriers to HIV care initiation

Timely treatment of HIV infection is a public health priority, yet many HIV-positive persons delay treatment initiation. We conducted a community-based study comparing HIV-positive persons who received an HIV diagnosis at least 3 months ago but had not initiated care (n=100) with a reference population of HIV-positive persons currently in care (n=115) to identify potential barriers to treatment initiation. Study participants were mostly male (78.0%), and persons of color (54.9% Latino, 26.3% black), with median age 37.8 years. Median time since HIV diagnosis was 3.7 years. Univariate analysis revealed that those never in care differed substantially from those currently in care with regard to sociodemographics; HIV testing and counseling experiences; perceived barriers to care; and knowledge, attitudes, and beliefs regarding HIV. Factors independently associated with never initiating HIV care were younger age (adjusted odds ratio [AOR]=0.93; 95% confidence interval [CI]: 0.88, 0.99), shorter time since diagnosis (AOR=0.87; 95% CI: 0.77, 0.98), lacking insurance (AOR=0.11; 95% CI: 0.03, 0.35), not knowing someone with HIV/AIDS (AOR=0.09; 95% CI: 0.03, 0.30) not disclosing HIV status (AOR=0.13; 95% CI: 0.02, 0.70), not receiving help making an HIV care appointment after diagnosis (AOR=0.04; 95% CI: 0.01, 0.14), and not wanting to think about being HIV positive (AOR=3.57; 95% CI: 1.22, 10.46). Our findings suggest that isolation and stigma remain significant barriers to initiating HIV care in populations consisting primarily of persons of color, and that direct linkages to HIV care at the time of diagnosis are critical to promoting timely care initiation in these populations.     

Role of male partner involvement in ART retention and adherence in Malawi’s Option B+ program

Malawi’s Option B+ program provides all HIV-infected pregnant women free lifelong antiretroviral therapy (ART), but challenges remain regarding retention and ART adherence, potentially due to male partner barriers. We explored relationships between male partner involvement and Option B+ retention and adherence. In 2014, a randomized controlled trial in Malawi compared male recruitment strategies for couple HIV testing and counseling (cHTC) at an antenatal clinic. This secondary analysis was conducted among the entire cohort (N?=?200) of women, irrespective of randomization status. We assessed whether cHTC attendance, early disclosure of HIV-positive status, and partner ART reminders were associated with retention and adherence at one month after starting treatment. Retention was defined as attending HIV clinic follow-up within one day of running out of pills. Adherence was defined as taking ≥95% of ARTs by pill count. We used binomial regression to calculate adjusted risk ratios (aRR) and 95% confidence intervals (CI). Median female age was 26 years. Most women (79%) were retained; of these, 68% were adherent. Receiving cHTC was associated with improved retention (aRR 1.33, 95% CI 1.12, 1.59). Receiving male partner ART reminders was weakly associated with retention (aRR 1.16, 95% CI 0.96, 1.39). Disclosure within one day was not associated with retention (aRR 1.08, 95% CI: 0.91, 1.28). Among those who were retained, these three behaviors were not associated with improved 95% adherence. CHTC could play an important role in improving Option B+ retention. Increasing cHTC participation and enhancing adherence-related messages within cHTC are important.     

Correlates of antiretroviral adherence and viral load among transgender women living with HIV

Transgender women are 49 times more likely to become HIV infected than other groups, yet they are drastically underserved by current treatment efforts and report lower rates of treatment adherence then other groups. The objective of this study was to explore correlates of antiretroviral (ART) adherence and viral load among HIV-positive transgender women on ART utilizing a cross-sectional survey of a convenience sample of 59 transgender women. In multivariate models of ART adherence, correlates were age, stress appraisal of transphobic experiences, importance of gender affirmation, and adherence to hormone therapy. In multivariate models of self-reported viral load, correlates were stress appraisal of transphobic experiences and being in a relationship. This study provides preliminary evidence of transgender-relevant correlates of ART adherence and viral load.     

Risk factors for treatment denial and loss to follow-up in an antiretroviral treatment cohort in Kenya

OBJECTIVES: To evaluate risk factors for treatment denial and loss to follow-up in an antiretroviral treatment (ART) cohort in a rural African setting in western Kenya. METHOD: Sociodemographic and clinical data of patients enrolled in an ART cohort were collected within 18 months of an observational longitudinal study and analysed by logistic and Cox regression models. RESULTS: Of 159 patients with treatment indication 35 (22%) never started ART. Pregnancy [adjusted odds ratio (AOR) 3.60, 95% confidence interval (CI) 1.10-11.8; P = 0.035] and lower level of education (AOR 3.80, 95% CI 1.14-12.7; P = 0.03) were independently associated with treatment denial. The incidence of total loss of patients under therapy was 43.2 per 100 person years (pys) (mortality rate 19.2 per 100 pys plus drop out rate 24 per 100 pys). Older age [adjusted hazard ratio (AHR) 1.06, 95% CI 1.01-1.12; P = 0.04], AIDS before starting treatment (AHR 5.83, 95% CI 1.15-29.5; P = 0.03) and incomplete adherence to treatment (AHR 1.05, 95% CI 1.03-1.07; P < 0.001) were independent risk factors for death. Incomplete adherence also independently predicted drop out because of other reasons (AHR 1.06, 95% CI 1.04-1.09; P < 0.001). CONCLUSION: Pregnancy and lower level of education, higher age, advanced AIDS stage and impaired compliance to ART were identified as risk factors for treatment denial and death, respectively. Adequate counselling strategies for patients with these characteristics could help to improve adherence and outcome of treatment programmes in resource-limited settings.     

Association of Depressive Symptoms with Lapses in Antiretroviral Medication Adherence Among People Living with HIV: A Test of an Indirect Pathway

Viral suppression, a critical component of HIV care, is more likely when individuals initiate antiretroviral therapy (ART) early in disease progression and maintain optimal levels of adherence to ART regimens. Although several studies have documented the negative association of depressive symptoms with ART adherence, less is known about how depressed mood relates to intentional versus unintentional lapses in adherence as well as the mechanisms underlying this association. The purpose of the current study was to examine the association of depressive symptoms with ART adherence, assessed as a multidimensional construct. Secondarily, this study conducted preliminary indirect path models to determine if medication self-efficacy could explain the depressed mood-adherence relationship. Depressive symptoms were not associated with 95% ART taken, self-reported viral load, deliberate adjustments to ART regimens or skipped ART doses. However, the indirect association of depressive symptoms via decrements in medication self-efficacy was significant for 95% ART taken, self-reported viral load and skipped ART doses, but not deliberate changes to ART regimens. In this sample of HIV-positive outpatients, there is evidence to support medication self-efficacy as a potential mechanism underlying the association between depressive symptoms and ART adherence. Additional longitudinal studies are needed to formally examine medication taking self-efficacy as a mediator.     

Predictors of HIV Care Engagement,Antiretroviral Medication Adherence,and Viral Suppression Among People Living with HIV Infection in St. Petersburg,Russia

Over 1 million HIV infections have been diagnosed in Russia, and HIV care uptake and viral suppression are very low. 241 HIV-positive individuals in St. Petersburg were enrolled through social networks, provided blood for viral load testing, and completed measures of medication-taking adherence, readiness, and self-efficacy; psychosocial well-being; and substance use. Outcomes included attending an HIV care appointment in the past 6 months, >90% ART adherence, and undetectable viral load. 26% of participants had no recent care appointment, 18% had suboptimal adherence, and 56% had detectable viral load. Alcohol use consistently predicted all adverse health outcomes. Having no recent care visit was additionally associated with being single and greater past-month drug injection frequency. Poor adherence was additionally predicted by lower medication-taking self-efficacy and lower anxiety. Detectable viral load was additionally related to younger age. Comprehensive interventions to improve HIV care in Russia must address substance abuse, anxiety, and medication-taking self-efficacy.     

Barriers to antiretroviral therapy initiation for HIV-positive children aged 2–18 months in Swaziland

Although early antiretroviral therapy (ART) reduces HIV-related mortality in children by up to 75%, almost half of HIV-positive children younger than 1 year old in Swaziland do not initiate ART. This study was conducted to identify barriers to early ART initiation among HIV-positive infants. This was a case-control study among HIV-positive infants, aged 2 to 18 months, who either did not initiate ART (cases), or initiated ART (controls), during 18 months after testing. Multivariable logistic regression showed that infants who visited the clinic every month, or every 2 months, were 5.78 and 6.20 times more likely to initiate ART than those who visited less often (OR 5.78, 95% CI 1.82–18.33 and OR 6.20, 95% CI 1.30–29.60 respectively). Children who lived ≤30 and 31–60 minutes from the nearest clinic were 84% and 79% less likely respectively to initiate ART (OR 0.16, 95% CI 0.03–0.78 and OR 0.21, 95% CI 0.04–0.98) compared with those who lived more than 60 minutes away. Children who received immunisation after 6 months were 22.59 times more likely to initiate ART (OR 22.59, 95% CI 7.00–21.72) than those who did not. Infants of caregivers who had excellent or good relationships with their healthcare provider were 4.32 times more likely to initiate ART (OR 4.32, 95% CI 1.01–18.59) than those of caregivers who had average or poor relationships with healthcare providers. The significant predictors of ART initiation identified in this study should be regarded as priority areas for intervention among HIV-positive women in Swaziland.