The UNAIDS 90-90-90 strategy clearly stipulates that 90% of all people on antiretroviral therapy (ART) should have a suppressed viral load. Intensified adherence counselling (IAC) was recently ...recommended by WHO to improve viral suppression among ART-treated paediatric and adolescent clients with virological failure. This paper describes the implementation and outcomes of IAC in the first year of implementation in a public ART program, to inform strategic interventions to reach the "third 90" among children.
A retrospective chart review was conducted for all children aged 9 months to 19 years with HIV viral loads (VL) ≥ 1000 copies/ml at 15 public health facilities from June 2015-December 2016. Data on initial VL test results, IAC sessions, repeat VL test results, and ART regimen switch were abstracted and analysed for completion of IAC and viral suppression after IAC.
A total of 449 children had a detectable viral load above 1000 copies/ml, after an average of 3.5 years (SD 5.8) years of ART. 192 (43%) were 10-20 years of age, and 320 (71%) were receiving Nevirapine-based ART regimen. Out of 345 (77%) who completed the recommended three IAC sessions, 62 (23%) achieved viral suppression following IAC. The mean time from 1st to 3rd IAC session was 113 (SD 153) days and 172 (50%) of the children had completed the three sessions within 200 days.
Suppression rates were low among ART-treated children with virological failure that completed the recommended three IAC sessions. As we move towards having 90% of ART-treated children and adolescents achieve and maintain viral suppression, there is need to re-evaluate the implementation of IAC among children and adolescents to consider both psychosocial and biological factors such as resistance testing for those with multiple detectable viral loads.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Of the estimated 130,000 children living with HIV in Uganda, 47% are receiving ART. Only 39.3% have suppressed HIV-1 viral load to levels below 50 copies per ml. Caregivers are key drivers of ...adherence to achieve viral suppression in children. We investigated the challenges and potential support required by caregivers of ART-treated children.
A qualitative study was conducted within the Infectious Diseases Institute paediatric ART program in Kampala and Hoima districts. Caregivers of children with viral loads above 1000 copies were purposively sampled and engaged in five focus group discussions (FGD). The FGD guide highlighted questions on challenges that caregivers face and the kind of support they required to improve children's ART adherence. Thematic analysis using the inductive approach was used. All the transcripts were read, coded and emergent themes determined.
Overall, 37 caregivers participated in five FGD, of whom 29 (78%) were female, 28 (76%) were HIV-infected and 25 (68%) were biological parents of the children. The elicited challenges were either in failure to attend the counselling sessions or in supporting adherence to medication. Individual and health system challenges such as competing priorities, logistics, poor quality of counselling and lack of reminders prevented attendance at counselling sessions. Five themes emerged as challenges to supporting adherence: i) environmental (school activities, working away from home), ii) personal (non-disclosure, stigma), iii) psychological (guilt), iv) financial (lack of food and transport) and v) child-related (fatigue and peer influence). Three major themes emerged for the support that caregivers needed namely: a) health system reforms (clinic appointments outside school hours, minimize ART drug stock outs and improve quality of counselling), b) psychosocial support (support with disclosure of HIV status to children and their families, more frequent peer support groups and parenting classes) and c) economic empowerment (training in vocational skills, school fees support and opportunities to initiate income generating activities).
To achieve viral suppression, ART programs require targeted efforts to provide specific health facility requirements, psychological and economic needs of ART-treated children and their caregivers. Integration of HIV treatment with programs for orphans and vulnerable children may improve viral suppression rates.
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Dostopno za:
CEKLJ, DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Although there is mounting evidence and policy guidance urging the integration of HIV services into general health systems in countries with a high HIV burden, vertical (stand-alone) HIV clinics are ...still common in Uganda. We sought to describe the specific contexts underpinning the endurance of vertical HIV clinics in Uganda.
A qualitative research design was adopted. Semi-structured interviews were conducted with the heads of HIV clinics, clinicians and facility in-charges (n = 78), coupled with eight focus group discussions (64 participants) with patients from 16 health facilities purposively selected, from a nationally-representative sample of 195 health facilities across Uganda, because they run stand-alone HIV clinics. Data were analyzed by thematic approach as guided by the theory proposed by Shediac-Rizkallah & Bone (1998) which identifies; Intervention characteristics, organizational context, and broader environment factors as potentially influential on health programme sustainability.
Intervention characteristics: Provider stigma was reported to have been widespread in the integrated care experience of participating health facilities which necessitated the establishment of stand-alone HIV clinics. HIV disease management was described as highly specialized which necessitated a dedicated workforce and vertical HIV infrastructure such as counselling rooms. Organizational context: Participating health facilities reported health-system capacity constraints in implementing integrated systems of care due to a shortage of ART-proficient personnel and physical space, a lack of laboratory capacity to concurrently conduct HIV and non-HIV tests and increased workloads associated with implementing integrated care. Broader environment factors: Escalating HIV client loads and external HIV funding architectures were perceived to have perpetuated verticalized HIV programming over the past decade.
Our study offers in-depth, contextualized insights into the factors contributing to the endurance of vertical HIV clinics in Uganda. Our analysis suggests that there is a complex interaction in supply-side constraints (shortage of ART-proficient personnel, increased workloads, laboratory capacity deficiencies) and demand-side factors (escalating demand for HIV services, psychosocial barriers to HIV care) as well as the specialized nature of HIV disease management which pose challenges to the integrated-health services agenda.
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Dostopno za:
CEKLJ, DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Despite facing a dual burden of HBV and HIV, Africa lacks experience in offering integrated care for HIV and HBV. To contextualize individual and group-level feasibility and acceptability of an ...integrated HIV/HBV care model, we explored perspectives of health care providers and care recipients on feasibility and acceptability of integration.
In two regional hospitals of West Nile region, we performed a demonstration project to assess feasibility and acceptability of merging the care of HBV-monoinfected patients with existing HIV care system. Using interviews with health care providers as key informants, and 6 focus groups discussions with 3 groups of patients, we explored feasibility (i)whether integration is perceived to fit within the existing healthcare infrastructure, (ii) perceived ease of implementation of HIV/HBV integrated care, and (iii) perceived sustainability of integration and acceptability whether the HIV/HBV care model is perceived as (i) suitable, (ii) satisfying and attractive (iii) there is perceived demand, need and intention to recommend its use. We audio-recorded the interviews and data was analysed using framework analysis.
The following themes emerged from the data (i) integrating HBV into HIV care is perceived to be feasible, fit and beneficial, after making requisite adjustments (ii) integration is acceptable due to the need for both free treatment and anticipated collaboration between HIV and HBV clients in terms of peer-support (iii) there are concerns about the likely rise in stigma and the lack of community awareness about integrated care.
The integrated HIV/HBV care model is feasible and acceptable among both providers and recipients. Necessary adjustments to the existing care system, including training, for community sensitization on the reasons and significance of integration are required.
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Dostopno za:
CEKLJ, DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Linkage of HIV-infected pregnant women to HIV care remains critical for improvement of maternal and child outcomes through prevention of maternal-to-child transmission of HIV (PMTCT) and subsequent ...chronic HIV care. This study determined proportions and factors associated with intra-facility linkage to HIV care and Early Infant Diagnosis care (EID) to inform strategic scale up of PMTCT programs.
A cross-sectional review of records was done at 2 urban and 3 rural public health care facilities supported by the Infectious Diseases Institute (IDI). HIV-infected pregnant mothers, identified through routine antenatal care (ANC) and HIV-exposed babies were evaluated for enrollment in HIV clinics by 6 weeks post-delivery.
Overall, 1,025 HIV-infected pregnant mothers were identified during ANC between January and June, 2012; 267/1,025 (26%) in rural and 743/1,025 (74%) in urban facilities. Of these 375/1,025 (37%) were linked to HIV clinics 67/267(25%) rural and 308/758(41%) urban. Of 636 HIV-exposed babies, 193 (30%) were linked to EID. Linkage of mother-baby pairs to HIV chronic care and EID was 16% (101/636); 8/179 (4.5%) in rural and 93/457(20.3%) in urban health facilities. Within rural facilities, ANC registration <28 weeks-of-gestation was associated with mothers' linkage to HIV chronic care AoR, 2.0 95% CI, 1.1-3.7, p = 0.019 and mothers' multi-parity was associated with baby's linkage to EID; AoR 4.4 (1.3-15.1), p = 0.023. Stigma, long distance to health facilities and vertical PMTCT services affected linkage in rural facilities, while peer mothers, infant feeding services, long patient queues and limited privacy hindered linkage to HIV care in urban settings.
Post-natal linkage of HIV-infected mothers to chronic HIV care and HIV-exposed babies to EID programs was low. Barriers to linkage to HIV care vary in urban and rural settings. We recommend targeted interventions to rapidly improve linkage to antiretroviral therapy for elimination of MTCT.
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Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
BACKGROUND:Circumcision has been shown to be an effective method of HIV prevention; however, only 27% of Ugandan men aged 15–49 years are circumcised. There is a paucity of data on the role of ...intimate partners in generating demand for voluntary medical male circumcision (VMMC). We conducted a pilot study to assess the feasibility of a partner-focused intervention targeting males >25 years.
METHODS:Among pregnant women in their third trimester attending antenatal care we evaluated the impact of a pilot behavior change intervention on VMMC through a quasi-experimental approach. We observed VMMC numbers among spouses of women as per standard practice (comparison phase), and after introducing a behavioral change communication package (intervention phase). Logistic regression was used to compare the odds of VMMC uptake between comparison and intervention phases. We used qualitative methods to evaluate the casual chain using a thematic approach.
RESULTS:Of the 601 women studied, 90% articulated the health benefits of VMMC and 99% expressed interest in their spouse getting circumcised. Womenʼs knowledge was not increased by the intervention. Four men were circumcised in the comparison and 7 in the intervention phase. The intervention was not associated with higher odds of circumcision (odds ratio 1.5, 95% CI0.3 to 6.0, P = 0.65). We interviewed 117 individuals overall with the main enablers for VMMC beingfree VMMC, transport reimbursement, and health benefits. Deterrents included misconceptions, lost wages and fear of pain. Most of the uncircumcised men interviewed reported interest in VMMC.
CONCLUSIONS:Our pilot intervention had no significant impact on increasing VMMC demand. The study demonstrated the feasibility of pregnant women engaging their spouses to discuss VMMC.
BackgroundHepatitis B and HIV care share health system challenges in the implementation of primary prevention, screening, early linkage to care, monitoring of therapeutic success and long-term ...medication adherence.SettingArua regional referral hospital (RRH) and Koboko district hospital (DH), the West Nile region of Uganda.DesignA cross-sectional hospital-based cost minimisation study from the providers’ perspective considers financial costs to measure the amount of money spent on resources used in the stand-alone and integrated pathways.Data sourcesClinic inputs and procurement invoices, budgetary documents, open market information and expert opinion. Data were extracted from 3121 files of HIV and hepatitis B virus (HBV) monoinfected patients from the two study sites.ObjectiveTo estimate provider costs associated with running an integrated HBV and HIV clinical pathway for patients on lifelong treatment in low-resource setting in Uganda.Outcome measuresThe annual cost per patient was simulated based on the total amount of resources spent for all the expected number of patient visits to the facility for HBV or HIV care per year.ResultsFindings showed that Arua hospital had a higher cost per patient in both clinics than did Koboko Hospital. The cost per HBV patient was US$163.59 in Arua and US$145.76 in Koboko while the cost per HIV patient was US$176.52 in Arua and US$173.23 in Koboko. The integration resulted in a total saving of US$36.73 per patient per year in Arua RRH and US$17.5 in Koboko DH.ConclusionThe application of the integrated Pathway in HIV and HBV patient management could improve hospital cost efficiency compared with operating stand-alone clinics.
The "2for1" project is a demonstration project to examine the feasibility and effectiveness of HBV care integrated into an HIV clinic and service. An initial phase in implementation of this project ...was the development of a specific training program. Our objective was to describe key features of this integrated training curriculum and evaluation of its impact in the initial cohort of health care workers (HCWs).
A training curriculum was designed by experts through literature review and expert opinion. Key distinctive features of this training program (compared to standard HBV training provided in the Government program) were; (i) Comparison of commonalities between HIV and HBV (ii) Available clinic- and community-level infrastructure, and the need to strengthen HBV care through integration (iii) Planning and coordination of sustained service integration. The training was aided by a power-point guided presentation, question and answer session and discussion, facilitated by physicians and hepatologists with expertise in viral hepatitis. Assessment approach used a self-administered questionnaire among a cohort of HCWs from 2 health facilities to answer questions on demographic information, knowledge and attitudes related to HBV and its prevention, before and after the training. Knowledge scores were generated and compared using paired t- tests.
A training curriculum was developed and delivered to a cohort of 44 HCWs including medical and nursing staff from the two project sites. Of the 44 participants, 20 (45.5%) were male, average age (SD) was 34.3 (8.3) with an age range of 22-58 years. More than half (24, 54.5%) had been in service for fewer than 5 years. Mean correct knowledge scores increased across three knowledge domains (HBV epidemiology and transmission, natural history and treatment) post-intervention. However, knowledge related to diagnosis and prevention of HBV did not change.
A structured HBV education intervention conducted as part of an HIV/HBV care integration training for health care workers yielded improved knowledge on HBV and identified aspects that require further training. This approach may be replicated in other settings, as a public health strategy to heighten HBV elimination efforts.
Male partner involvement has been shown to increase mothers' uptake of Prevention of Mother-to-Child Transmission of HIV (PMTCT) and improve maternal and infant HIV treatment outcomes. Currently, ...male involvement in PMTCT is measured primarily through men's attendance at HIV testing and counselling which may not be a true reflection of their engagement. This study therefore set out to explore the meaning of male partner involvement and propose a definition and theoretical model of this concept in PMTCT in Uganda.
Eight focus group discussions and five in-depth interviews were conducted with couples at three public health facilities and community members in the health facility catchment areas in Uganda. The study employed a grounded theory approach underpinned by the pragmatic philosophical paradigm. Data were analyzed using the constant comparative method, performing three levels of open, axial, and selective coding.
Of the 61 participants, 29 (48%) were male and the majority 39 (63.9%) were in long term marital relationships, while about half were self-employed 29 (47.5%). Three themes emerged for the meaning of male involvement in PMTCT (a) HIV treatment support (b) economic support and (c) psychosocial support. HIV treatment support included adherence support, couples' HIV counseling and testing, and clinic attendance during and after pregnancy. Participants expressed that men were engaged in PMTCT when they offered economic support by providing basic needs and finances or when they included their female partners in financial planning for the family. Psychosocial support arose from the female participants who defined male involvement as family support, perceived societal recognition and emotional support. Emotional support also included the absence of harm resulting from women's disclosure of HIV test results to their male partner.
This study proposes a new definition for male partner involvement in PMTCT in Uganda. The definition extends beyond men's clinic attendance and HIV testing and counselling. Further research should seek to develop and validate tools to accurately measure male partner involvement as the next step in the development of interventions to improve PMTCT outcomes.
Celotno besedilo
Dostopno za:
CEKLJ, DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
HIV self-testing (HIVST) was adopted for key populations (KPs) and sexual partners of pregnant and lactating women (mothers) in Uganda in October 2018. We report early observations during HIVST ...implementation in Kampala, Uganda.
HIVST was rolled out to reach those with unknown HIV status at 38 public health facilities, using peer-to-peer community-based distribution for female sex workers (FSW) and men who have sex with men (MSM) and secondary distribution for mothers, who gave HIVST kits to their partners. Self-testers were asked to report results within 2 days; those who did not report received a follow-up phone call from a trained health worker. Those with HIV-positive results were offered confirmatory testing at the facility using the standard HIV-testing algorithm. Data on kits distributed, testing yield, and linkage to care were analysed.
We distributed 9,378 HIVST kits. Mothers received 5,212 (56%) for their sexual partners while KPs received 4,166 (44%) (MSM, 2192 53%; FSW1, 974, 47%). Of all kits distributed, 252 (3%) individuals had HIV-positive results; 126 (6.5%) FSW, 52 (2.3%) MSM and 74 (1.4%) partners of mothers. Out of 252 individuals who had HIV-positive results, 170 (67%) were confirmed HIV-positive; 36 (2%) were partners of mothers, 99 (58%) were FSW, and 35 (21%) were MSM. Linkage to treatment (126) was 74%.
HIVST efficiently reached, tested, identified and modestly linked to care HIV positive FSW, MSM, and partners of mothers. However, further barriers to confirmatory testing and linkage to care for HIV-positive self-testers remain unexplored.
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