Equity and HIV/AIDS

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.

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.