Equity and HIV/AIDS

Patient and nurse perspectives of a nurse-led community-based model of HIV care delivery in Malawi: a qualitative study
Sande O; Burtscher D; Kathumba D; Tweya H; et al: BMC Public Health 20(685), 1-8, 2020

The authors explored how the nurse-led community-based ART programme in Malawi was perceived, through interview of patients and nurses providing the care. Patients reported saving money on transportation and the time it took them to travel to a health facility. Caseloads and waiting times were also reduced, which made patients more comfortable and gave nurses the time to conduct thorough consultations. Closer relationships were built between patients and care providers, creating a space for more open conversations. Patients’ nutritional needs and concerns related to stigma remain a concern, while operational issues affect the quality of the services provided in the community. The patients interviewed in this study preferred the nurse-led community ART programme approach to the facility-based model of care because of the features above. The authors note that community-led healthcare programmes need to plan for the provision of transportation for care providers; the physical structure of community sites; the timely consolidation of data collected in the field to a central database; and the need for care providers to cover multiple facility-based staff roles.

Prevalence and determinants of recent HIV testing among older persons in rural Uganda: a cross-sectional study
Wandera S; Kwagala B; Maniragaba F: BMC Public Health 20(144) 1-10, 2020

This study investigated the socio-demographic determinants of recent HIV testing among older persons in selected rural districts in Uganda using a cross-sectional survey of 649 older men and women age 50 years and older, from central and western Uganda. Prevalence of lifetime HIV testing was 82% and recent HIV testing was 53%. HIV testing in the last 12 months was associated with age, self-reported sexually transmitted infections, male circumcision, and sexual activity in the last 12 months. Recent HIV testing among older persons was associated with younger age, self-reported STIs, male circumcision, and sexual activity among older persons in rural Uganda. The authors propose that HIV testing interventions target persons 70 years and older, who were less likely to test.

HIV self-testing services for female sex workers, Malawi and Zimbabwe
Napierala S; Desmond N; Kumwenda M; Tumushime M; et al.: Bulletin of the World Health Organization 97(11) 764–776, 2019

n Zimbabwe, research was conducted to assess the acceptability and accuracy of human immunodeficiency virus (HIV) self-testing. During implementation, the authors evaluated sex workers’ preferences for and feasibility of distribution of test kits before the programme was scaled-up. In Malawi, the authors conducted a rapid ethnographic assessment to explore the context and needs of female sex workers and resources available, leading to a workshop to define the distribution approach for test kits. Once distribution was implemented, the authors conducted a process evaluation and established a system for monitoring social harm. In Zimbabwe, female sex workers were able to accurately self-test. The preference study helped to refine systems for national scale-up through existing services for female sex workers. The qualitative data helped to identify additional distribution strategies and mediate potential social harm to women. In Malawi, peer distribution of test kits was the preferred strategy. The authors identified some incidents of social harm among peer distributors and female sex workers, as well as supply-side barriers to implementation which hindered uptake of testing. Involving female sex workers in planning and ongoing implementation of human immunodeficiency virus self-testing is essential, along with strategies to mitigate potential harm. Optimal strategies for distribution and post-test support are argued to be context-specific and to need to consider existing support for female sex workers and levels of trust and cohesion within their communities.

Preference and uptake of different community-based HIV testing service delivery models among female sex workers along Malaba-Kampala highway, Uganda, 2017
Pande G; Bulage L; Kabwama S; Nsubuga F: BMC Health Services Research 19(799) 1-11, 2019

The paper assessed preference and uptake for the enabling environment created to deliver the different community-based HIV testing services to female sex workers along the Malaba-Kampala highway. Malaba – Kampala high way is one of the major high ways with many different hot spots where the actual buying and selling of sex takes place. The authors defined female sex workers as any female, who undertakes sexual activity after consenting with a man for money or other items/benefits as an occupation or as a primary source of livelihood irrespective of site of operation within the past six months. The authors assessed the preference and uptake of different community-based HIV testing services delivery model among female sex workers based on the proportion of female sex workers who had an HIV counseling and testing in the last 12 months and the proportion of female sex workers who were positive and linked to care. Overall, 86% of the female sex workers had taken an HIV test in the last 12 months. Of the 390 Female Sex workers, 72% had used static facilities, 25% had used outreaches, and 3.3% used peer to peer mechanisms to have an HIV test. Overall, 35% of the female sex workers who had taken an HIV test were HIV positive. Of the 159, 83% were successfully linked into care. Ninety one percent reported to have been linked into care by static facilities. Challenges experienced included; lack of trust in the results given during outreaches, failure to offer other testing services including hepatitis B and syphilis during outreaches, inconsistent supply of testing kits, condoms, STI drugs, and unfriendly health services due to the infrastructure and non-trained health workers delivering KP HIV testing services. Most of the Female Sex workers had HIV counseling and testing services and were linked to care through static facilities. Community-based HIV testing service delivery models are challenged with inconsistent supply of HIV testing commodities and unfriendly services. The authors recommended strengthening of all HIV testing community-based HIV testing service delivery models by ensuring constant supply of HIV testing/AIDS care commodities offering Female Sex workers friendly services, and provision of comprehensive HIV/AIDS health care package.

Integrating community health assistant-driven sexual and reproductive health services in the community health system in Nyimba district in Zambia: mapping key actors, points of integration, and conditions shaping the process
Zulu J; Kinsman J; Hurtig A; Michelo C; et al: Reproductive Health 16(122) 1-11, 2019

This study aimed to identify the conditions and strategies through which Community Health Assistants gained entry and acceptability into community health systems to provide sexual and reproductive health services services to youth in Nyimba district, Zambia. Community Health Assistants worked with a range of community actors, including other health workers, safe motherhood action groups, community health workers, neighborhood health committees, teachers, as well as political, traditional and religious leaders and took services to health facilities, schools, police stations, home settings, and community spaces. They used their health facility service delivery role to gain trust and entry into the community, and built relationships with other community level actors by holding regular joint meetings, and acting as brokers between the volunteer health workers and the Ministry of Health. They used their existing social networks to deliver sexual and reproductive health services to adolescents, and embedded this into general life skills at community level, the improving its acceptability. Support from community leaders also promoted their legitimacy. The acceptability of their services was limited by a taboo of discussing sexuality issues, a gender discriminatory environment, competition with other providers, and challenges in conducting household visits.

Hypertension control in integrated HIV and chronic disease clinics in Uganda in the SEARCH study
Kwarisiima D; Atukunda M; Owaraganise A; Chamie G; et al: BMC Public Health 19(511) 1-10, 2019

This paper looks at the increasing burden of hypertension across sub-Saharan Africa where HIV prevalence is the highest in the world, but current care models are inadequate to address the dual epidemics. Little data exist on the effectiveness of integrated HIV and chronic disease care delivery systems on blood pressure control over time. Population screening for HIV and hypertension, among other diseases, was conducted in ten communities in rural Uganda as part of the SEARCH study. Individuals with either HIV, hypertension, or both were referred to an integrated chronic disease clinic. Based on Uganda treatment guidelines, follow-up visits were scheduled every 4 weeks when blood pressure was uncontrolled, and either every 3 months, or in the case of drug stock-outs more frequently, when blood pressure was controlled. The authors described demographic and clinical variables among all patients and used multilevel mixed-effects logistic regression to evaluate predictors of hypertension control. Following population screening of 34,704 adults age ≥ 18 years, 4554 individuals with hypertension alone or both HIV and hypertension were referred to an integrated chronic disease clinic. Within 1 year 2038 participants with hypertension linked to care and contributed 15,653 follow-up visits over 3 years. Hypertension was controlled at 15% of baseline visits and at 46% of post-baseline follow-up visits. Hypertension control at follow-up visits was higher among HIV-infected patients than uninfected patients and improved hypertension control was achieved in an integrated HIV and chronic care model.

Understanding factors influencing linkage to HIV care in a rural setting, Mbeya, Tanzania: qualitative findings of a mixed methods study
Sanga E; Mukumbang F; Mushi A; Lerebo W; et al: Biological Medical Central Public Health 19(383), 1-15, 2019

This study explored facilitators and barriers to linkage to HIV care at individual/patient, health care provider, health system, and contextual levels to inform the design of interventions to improve linkages to HIV care. The authors conducted a descriptive qualitative study nested in a cohort study of 1012 newly diagnosed HIV-positive individuals in Mbeya region Tanzania between August 2014 and July 2015. The authors identified multiple factors influencing linkage to care. HIV status disclosure, support from family/relatives and having symptoms of disease were reported to facilitate linkage at the individual level. Fear of stigma, lack of disclosure, denial and being asymptomatic, belief in witchcraft and spiritual beliefs were barriers identified at individual’s level. At providers’ level; support and good patient-staff relationship facilitated linkage, while negative attitudes and abusive language were reported barriers to successful linkage. Clear referral procedures and well-organized clinic procedures were system-level facilitators, whereas poorly organized clinic procedures and visit schedules, overcrowding, long waiting times and lack of resources were reported barriers. Distance and transport costs to HIV care centres were important contextual factors influencing linkage to care. The authors argue that interventions must address issues around stigma, denial and inadequate awareness of the value of early linkage to care.

Implementing prevention policies for mother-to-child transmission of HIV in rural Malawi, South Africa and United Republic of Tanzania, 2013–2016
Jones H; Wringe A; Todd J; Songo J; et al: Bulletin of the World Health Organisation 97(3) 200–212, 2019

This study assessed the adoption of World Health Organization guidance into national policies for prevention of mother-to-child transmission (PMTCT) of human immunodeficiency virus and monitored implementation of the guidelines at facility level in rural Malawi, South Africa and the United Republic of Tanzania. The authors summarized national PMTCT policies and World Health Organization guidance for 15 indicators across the cascades of maternal and infant care over 2013–2016. Two survey rounds were conducted in 46 health facilities serving five health and demographic surveillance system populations. Structured questionnaires were administered to facility managers to describe service delivery. In all countries, national policies influencing the maternal and infant prevention of mother-to-child transmission cascade of care aligned with World Health Organization guidelines by 2016; most inter-country policy variations concerned linkage to routine human immunodeficiency virus care. The proportion of facilities delivering post-test counselling, same-day antiretroviral therapy initiation, antenatal care and antiretroviral therapy provision in the same building, and Option B+ increased or remained at 100% in all sites. Progress in implementing policies on infant diagnosis and treatment varied across sites. Stock-outs of human immunodeficiency virus test kits or antiretroviral drugs in the past year declined overall, but were reported by at least one facility per site in both rounds. Progress has been made in implementing prevention of mother-to-child transmission policy in these settings. However, persistent gaps across the infant cascade of care and supply-chain challenges, risk undermining infant human immunodeficiency virus elimination goals.

Noncommunicable disease burden among HIV patients in care: a national retrospective longitudinal analysis of HIV-treatment outcomes in Kenya, 2003-2013
Achwoka D; Waruru A; Chen T; Masamaro K; et al: Biological Medical Central Public Health 19(372) 1-10, 2019

This paper sought to estimate the burden of noncommunicable diseases (NCDs) among people living with HIV (PLHIV) enrolled in HIV care and treatment in Kenya between 2003 and 2013. The authors conducted a nationally representative retrospective medical chart review of HIV-infected adults aged ≥15 years enrolled in HIV care in Kenya from October 1, 2003 through September 30, 2013. The authors estimated proportions of four NCDs categories among PLHIV at enrolment into HIV care, and during subsequent HIV care visits from 3170 records of PLHIV, 2115 of whom were women and just over half from PLHIVs aged above 35 years. Close to two-thirds of PLHIVs were on ART. The proportion of any documented NCD among PLHIV was 11.5%, with elevated blood pressure as the most common NCD. Despite this observation, only 17 patients had a corresponding documented diagnosis of hypertension in their medical record. Overall NCD incidence rates for men and women were and 31.6%, slightly more in men than in women but with no differences in NCD incidence rates by marital or employment status. At one year of follow up 43.8% of PLHIV not on ART had been diagnosed with an NCD compared to 3.7% of patients on ART; at five years the proportions with a diagnosed NCD were 88.8 and 39.2%, respectively. PLHIV in Kenya are thus noted to have a high prevalence of NCD, but in the absence of systematic, effective screening, the NCD burden is likely to be underestimated in this population. The authors recommend that systematic screening and treatment for NCDs using standard guidelines be integrated into HIV care and treatment programs in sub-Saharan Africa.

Factors affecting the acceptability of isoniazid preventive therapy among healthcare providers in selected HIV clinics in Nairobi County, Kenya: a qualitative study
Wambiya E; Atela M; Eboreime E: Infectious Diseases 8(12), doi: 10.1136/bmjopen-2018-024286, 2018

Despite being globally recommended as an effective intervention in tuberculosis (TB) prevention among people living with HIV, isoniazid preventive therapy (IPT) implementation remains limited, especially in sub-Saharan Africa. This study explored the factors influencing the acceptability of IPT among healthcare providers in selected HIV clinics in Nairobi County, Kenya, a high HIV/TB burden country. A qualitative study was conducted using in-depth interviews with healthcare providers in selected HIV clinics in Nairobi County, Kenya. Provider acceptability of IPT was influenced by the organisational context, provider training, perceptions of its efficacy, the clarity of IPT guidelines and procedures and the work environment. Inadequate high-level commitment and support for the IPT programme by programme managers and policy-makers were found to be the major barriers to successful IPT implementation. The authors argue for expanded engagement by policy-makers and IPT programme managers with providers and patients, as well as on-the-job design specific actions to support providers in implementation.