Equity and HIV/AIDS

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.

What do the implementation outcome variables tell us about the scaling-up of the antiretroviral treatment adherence clubs in South Africa? A document review.
Mukumbang F; Zaida Orth Z; van Wyk B: Health Research Policy and Systems 17(28) 1-12, 2019

This study reviewed the effectiveness of the rollout of the antiretroviral adherence clubs in South Africa. The authors did a thematic analysis of 32 documents on the adherence clubs programme found in various databases from December 2017 to July 2018. The analysis showed that adherence clubs were highly acceptable as they decongested clinics, increased social support for patients and had a low cost of implementation. Evidence suggests that the model was effective in improving adherence to antiretroviral treatment and retention in care. Based on the success of the clubs in the Western Cape, adherence clubs are currently being implemented in all of the other South African provinces. The challenges include acquiring additional resources and support and the efficient use of available resources. They can be addressed by increasing communication between stakeholders and fostering a culture of learning between facilities, and the authors recommend this as the programme expands.

How climate change is undermining the war against HIV in Africa
Lazareva I: Business Day, January 2019

In a study looking at the link between climate change and HIV infection since antiretroviral (ARV) treatment drugs became widely available in Sub-Saharan Africa, researchers found that severe drought threatens to drive new HIV infections. In the urban areas of Lesotho researchers looked at, droughts were linked to an almost five-fold increase in the number of girls selling sex and a three-fold increase in those being forced into sexual relations. Such findings mean climate shocks — which can bring displacement, loss of income and other problems — threaten to undermine progress made in HIV treatment, said Andrea Low, an assistant professor of epidemiology at the International Centre for AIDS Care and Treatment Programmes at Columbia University. “I think the real concern is that we have gained a lot in terms of epidemic control ... but there is always a possibility of losing all those gains if a lot of people are displaced due to climate extremes [and] forced migration.” People forced to migrate as a result of drought may no longer have easy access to the support of family and friends or to HIV treatment. The researchers indicate that said ways of reducing HIV risk associated with climate shocks include providing easier access to medical care, distributing HIV self-testing kits and offering cash transfers to pay school fees for drought-hit families forced to migrate.

HIV prevalence in young people and children living on the streets, Kenya
Braitstein P; Ayuku D; DeLong A; Makori D; et al: Bulletin World Health Organisation 97(1) 33–41, 2019

This paper seeks to obtain an estimate of the size of and human immunodeficiency (HIV) prevalence among, young people and children living on the streets of Eldoret, Kenya. The authors counted young people and children using a point-in-time approach, ensuring the authors reached a target population by engaging relevant community leaders during the planning of the study. The authors acquired point-in-time count data over a period of 1 week between the hours of 08:00 and 23:00, from both a stationary site and by mobile teams. Participants provided demographic data and a fingerprint and were encouraged to speak with an HIV counsellor and undergo HIV testing. Of the 1419 eligible participants counted, 1049 were male with a median age of 18 years. Of the 1029 who spoke with a counsellor, 1004 individuals accepted HIV counselling and 947 agreed to undergo an HIV test. Combining those who were already aware of their HIV-positive status with those who were tested during this study resulted in an overall HIV seroprevalence of 4.1%. The seroprevalence was 2.7% for males and 8.9% for females. The authors observed an increase in seroprevalence with increasing age for both sexes, but of much greater magnitude for females. By counting young people and children living on the streets and offering them HIV counselling and testing, the authors could obtain population-based estimates of HIV prevalence.

A longitudinal review of national HIV policy and progress made in health facility implementation in Eastern Zimbabwe
Tlhajoane M; Masoka T; Mpandaguta E; Rhead R; et al: Health Research Policy and Systems 16 (92) 1-13, 2018

In this longitudinal study from 2013 to 2015 the authors sought to establish how World Health Organization (WHO) HIV guidelines changes have been translated into national policy in Zimbabwe and to measure progress in implementation within local health facilities. National HIV programme policy guidelines published between 2003 and 2013 and 2014 and 2015 were reviewed to assess adoption of WHO recommendations on HIV testing services, prevention of mother-to-child transmission of HIV, and provision of antiretroviral therapy (ART). Changes in local implementation of these policies over time were measured in two rounds of a survey conducted at 36 health facilities in Eastern Zimbabwe in 2013 and 2015. High levels of adoption of WHO guidance into national policy were recorded, including adoption of new recommendations made in 2013–2015. New strategies to implement national HIV policies were introduced such as the decentralisation of ART services from hospitals to clinics and task-shifting of care from doctors to nurses. The proportions of health facilities offering free HIV testing and counselling, prevention of mother-to-child transmission and ART services increased substantially from 2013 to 2015, despite reductions in numbers of health workers. Provision of provider-initiated HIV testing remained consistently high. At least one test-kit stock-out in the prior year was reported in most facilities. Stock-outs of first-line ART and prophylactic drugs for opportunistic infections remained low. Repeat testing for HIV-negative individuals within 3 months decreased. Laboratory testing remained low across both survey rounds, despite policy and operational guidelines to expand coverage of diagnostic services. Good progress has been made in implementing international guidance on HIV service delivery in Zimbabwe. The authors suggest that further novel implementation strategies may be needed to achieve the latest targets for universal ART eligibility.

Who are the male partners of adolescent girls and young women in Swaziland? Analysis of survey data from community venues across 19 DREAMS districts
Reynolds Z; Gottert A; Luben E; et al: PLOS One, doi: https://doi.org/10.1371/journal.pone.0203208, 2017

Adolescent girls and young women (AGYW, ages 15–24) are at high risk of HIV in Swaziland and understanding more about their male sexual partners can inform HIV prevention efforts for both. Using the PLACE methodology across all 19 DREAMS implementation districts, 843 men ages 20–34 were surveyed between December 2016-February 2017. Surveys were conducted at 182 venues identified by community informants as places where AGYW and men meet/socialize. In multivariate analyses, men who reported three or more AGYW partners in the last year were more likely to be HIV-positive. Men were also less likely to disclose their HIV status to adolescent versus older partners and partners more than 5 years younger than themselves. Results also revealed relatively high unemployment and mobility, substantial financial responsibilities, and periodic homelessness. Most men identified through community venues reported relationships with AGYW, and these relationships demonstrated substantial HIV risk. Challenging life circumstances suggest structural factors may underlie some risk behaviours. Engaging men in HIV prevention and targeted health services is argued to be critical, and informant-identified community venues are suggested to be promising intervention sites to reach high-risk male partners of AGYW.

Associations between health systems capacity and mother-to-child HIV prevention program outcomes in Zambia
Price J; Chi B; Phiri W: PLOS ONE 13(9), doi: https://doi.org/10.1371/journal.pone.0202889, 2018

In this study, the authors investigated the association between health system capacity and use of prevention of mother-to-child HIV transmission (PMTCT) services in Zambia. They analyzed data from two studies conducted in rural and semi-urban Lusaka Province in 2014–2015. Among 29 facilities, the median overall facility score was 72. Median domain scores were: patient satisfaction 75; human resources 85; finance 50; governance 82; service capacity 77; service provision 60. The programmatic outcome was measured from 804 HIV-infected mothers. Median community-level antiretroviral use at 12 months was 81%. Patient satisfaction was the only domain score significantly associated with 12-month maternal antiretroviral use. When the authors excluded the human resources and finance domains, a positive association between composite 4-domain facility score and 12-month maternal antiretroviral use in peri-urban but not rural facilities was found. In these Zambian health facilities, patient satisfaction was positively associated with maternal antiretroviral 12 months postpartum. The association between overall health system capacity and maternal antiretroviral drug use was stronger in peri-urban versus rural facilities.

High rates of smoking in people with HIV in sub-Saharan Africa
Carter M: Aidsmap, September 2018

This research analysed data from the Demographic and Health Surveys (DHS) and AIDS Indicator Surveys (AIS) from 25 sub-Saharan African countries to determine prevalence of cigarette smoking and use of smokeless tobacco according to HIV status. Cross-sectional data were collected between 2005 and 2015 from adults aged between 15 and 59 years. As well as HIV status, data were also collected on gender, marital/relationship status, level of education, income, area of residence (rural/urban) and employment status. These factors were taken into account in statistical analyses of the association between HIV status and tobacco use. Turning to HIV, the prevalence of smoking was higher among HIV-positive than HIV-negative individuals (10.6% vs 8.1%). Analysis by gender showed that 25.9% of HIV-positive men and 1.2% of HIV-positive women smoked, significantly higher than the 16.1% and 0.7% prevalence seen in HIV-negative men and women, respectively. Country-level analyses showed considerable variability in tobacco use between individual countries. The prevalence of smoking ranged from 2.4% in Ghana to 19.9% in Lesotho. Over half of countries (14 of 25) showed a higher smoking prevalence among people with HIV. The difference was significant in five countries: Gambia, Niger, Swaziland, Zambia and Zimbabwe. But in Ethiopia and Namibia, HIV-positive participants were less likely to smoke than HIV-negative ones. The investigators acknowledge a number of limitations, including the cross-sectional design of their study, failure to collect data on frequency and intensity of tobacco use and a lack of data on use of antiretroviral therapy.

HIV self-testing perceptions, delivery strategies, and post-test experiences among pregnant women and their male partners in Central Uganda
Matovu J; Kisa R; Buregyeya E; et al: Global Health Action 11(1503784) 1-12, 2018

This was a qualitative study was conducted in Central Uganda between February and March 2017 through 32 in-depth interviews to document women and men’s perceptions about HIV self-testing (HIVST) strategies used by women in delivering the kits to their male partners, male partners’ reactions to receiving kits from their female partners, and positive and negative social outcomes post-test. Women were initially anxious about their male partners’ reaction if they brought HIVST kits home, but the majority eventually managed to deliver the kits to them successfully. Women who had some level of apprehension used a variety of strategies to deliver the kits including placing the kits in locations that would arouse male partners’ inquisitiveness or waited for ‘opportune’ moments when their husbands were likely to be more receptive. A few women lied about the purpose of the test kit while one woman stealthily took a mucosal swab from the husband. Most men initially doubted the ability of oral HIVST kits to test for HIV, but this did not stop them from using them. Both men and women perceived HIVST as an opportunity to learn about each other’s HIV status. No serious adverse events were reported post-test. The author’s findings lend further credence to the feasibility of female-delivered HIVST to improve male partner HIV testing in sub-Saharan Africa. They suggest that women need support in challenging relationships to minimize potential for deception and coercion.