African Journal of AIDS Research

Barriers to linkage and retention in HIV care still persist among adolescent girls and young women in western Kenya

2023-10-06T09:58:27+00:00

Adolescent girls and young women (AGYW) in sub-Saharan Africa experience delayed linkage to and poor retention in HIV care. Identifying and addressing specific barriers in HIV care programming is important to achieving the upgraded UNAIDS 95-95-95 targets and epidemic control. We examined these challenges among 103 HIV-positive AGYW in and out of HIV care in communities around Lake Victoria in western Kenya as part of a larger qualitative study to identify drivers of HIV testing and HIV care utilisation in key populations. We used the social-ecological model to guide development of interview guides. Individual-level barriers included denial and forgetfulness and gendered household responsibilities, medication side effects, especially if taken without food, pills being too big and difficult to swallow and the burden of a daily medication-taking regimen. Interpersonal barriers included troubled family relationships and pervasive fears of stigma and discrimination by friends and family. Communitylevel barriers were stigmatising attitudes toward people living with HIV. Health-system barriers included negative provider attitudes and confidentiality breaches. At the structural level, participants noted high costs due to long travel times to facilities, long clinic waiting times, household food insecurity and school and work commitments. AGYW’s limited decision-making autonomy due to age and gender norms, including their reliance on the authority of older adults, makes these barriers especially troubling. Innovative treatment approaches that take into account the unique vulnerabilities of AGYW are urgently needed.

Factors associated with patients defaulting on HIV treatment at Helen Joseph Hospital, Gauteng province, South Africa

2023-10-06T10:29:27+00:00

Background: South Africa’s government has made significant improvements in expanding access to antiretroviral (ARV) treatment. A rate of adherence of 95% to 100% is necessary to achieve the intended outcomes of antiretroviral treatment. However, antiretroviral treatment adherence remains a significant challenge at Helen Joseph Hospital, where an adherence rate of 51% to 59% has been reported.

Objective: The goal of this study was to examine the factors associated with ARV therapy non-adherence among HIV patients at Helen Joseph Hospital.

Method: The study used a case-control design. There were 32 570 eligible patients for this study and 322 were selected from the overall population. Epi Info™ 7.2 was used to calculate the sample size. A total of 322 questionnaires were administered to participants during their clinic visits. The Aids Clinical Trial Group (ACTG) Questionnaire was used to measure and describe factors associated with ART treatment defaulting. Epi Info™ 7.2 was used to calculate crude odds ratios and SPSS version 26 was used to conduct multivariate logistic regression to compute adjusted odds ratios at 95% confidence intervals and p-values.

Results: In total, there were 322 (100%) study participants, of which 51% (n = 165) were non-adherent to ARV therapy and 49% (n = 157) were adherent. Participants’ ranged between 19 and 58 years old, with a mean age of 34 years old and a standard deviation of 8.03 years. Treatment non-adherence was associated with long waiting times at Helen Joseph’s Themba Lethu Clinic after adjusting for gender, age, educational level and employment status. The adjusted odds ratio was 4.78, 95% CI 1.12–20.42, and p = 0.04.

Conclusion: The study explored factors associated with ARV treatment defaults at Helen Joseph hospital. The long waiting times at the hospital were strongly associated with non-adherence to ARV treatment. A reduction in clinic waiting times will result in improved adherence to ARV treatment. To reduce long waiting times, the study recommends a multi-month medication dispensing programme and differentiation of HIV care. We recommend that future research include patients and clinic managers (as well as other key players) in the development of solutions to reduce waiting times.

Contribution: Helen Joseph Hospital did not view long waiting times as a factor that would cause a patient to default on their ARV treatment in the past. Helen Joseph Hospital’s management team was influenced by the study results. To achieve an adherence rate of 95% to 100%, the hospital is reducing waiting times.

Assessing the impact of the COVID-19 restrictions on HIV testing services in Malawi: an interrupted time series analysis

2023-10-06T10:34:53+00:00

Background: Restrictions on public gatherings and movement to mitigate the spread of COVID-19 may have disrupted access and availability of HIV services in Malawi. We quantified the impact of these restrictions on HIV testing services in Malawi.

Methods: We conducted an interrupted time series analysis of routine aggregated programme data from 808 public and private, adult and paediatric health facilities across rural and urban communities in Malawi between January 2018 and March 2020 (pre-restrictions) and April to December 2020 (post restrictions), with April 2020 as the month restrictions took effect. Positivity rates were expressed as the proportion of new diagnoses per 100 persons tested. Data were summarised using counts and median monthly tests stratified by sex, age, type of health facility and service delivery points at health facilities. The immediate effect of restriction and post-lockdown outcomes trends were quantified using negative binomial segmented regression models adjusted for seasonality and autocorrelation.

Results: The median monthly number of HIV tests and diagnosed people living with HIV (PLHIV) declined from 261 979 (interquartile range [IQR] 235 654–283 293) and 7 929 (IQR 6 590–9 316) before the restrictions, to 167 307 (IQR 161 122–185 094) and 4 658 (IQR 4 535–5 393) respectively, post restriction. Immediately after restriction, HIV tests declined by 31.9% (incidence rate ratio [IRR] 0.681; 95% CI 0.619–0.750), the number of PLHIV diagnosed declined by 22.8% (IRR 0.772; 95% CI 0.695–0.857), while positivity increased by 13.4% (IRR 1.134; 95% CI 1.031–1.247). As restrictions eased, total HIV testing outputs and the number of new diagnoses increased by an average of 2.3% each month (slope change: 1.023; 95% CI 1.010–1.037) and 2.5% (slope change:1.025; 95% CI 1.012–1.038) respectively. Positivity remained similar (slope change: 1.001; 95% CI 0.987–1.015). Unlike general trends noted, while HIV testing services among children aged <12 months declined 38.8% (IRR 0.351; 95% CI 0.351–1.006) with restrictions, recovery has been minimal (slope change: 1.008; 95% CI 0.946–1.073).

Conclusion: COVID-19 restrictions were associated with significant but short-term declines in HIV testing services in Malawi, with differential recovery in these services among population subgroups, especially infants. While efforts to restore HIV testing services are commendable, more nuanced strategies that promote equitable recovery of HIV testing services can ensure no subpopulations are left behind.

Psychosocial support services to enhance well-being of orphaned and vulnerable learners in Eswatini early childhood centres and primary schools

2023-10-06T11:02:34+00:00

In Eswatini (formerly Swaziland), the increasing number of orphans and vulnerable children due to HIV/AIDS has spurred demand for psychosocial support services. When the Ministry of Education and Training assumed responsibility for delivering psychosocial support, educators were burdened with the additional role of looking after orphans and vulnerable learners. This exploratory, sequential, mixed- methods study was employed to analyse factors that enhance the provision of psychosocial support services and the perceptions of educators towards psychosocial support delivery. The qualitative study phase entailed 16 in-depth interviews with multi-sectoral psychosocial support specialists and seven focus group discussions with orphans and vulnerable learners. In the quantitative study phase, 296 educators were surveyed. Thematic analysis was used for the qualitative data, and the quantitative data was analysed using Statistical Package for the Social Sciences version 25 software. The findings reveal problems associated with psychosocial support service delivery at strategy, policy and operational levels. The results indicate that orphans and vulnerable children are offered material support (e.g. food and sanitary pads) and spiritual support, but were rarely referred for social and psychological needs. There were no proper counselling facilities and not all teachers received relevant training in children’s psychosocial needs. Training of educators in specific psychosocial support areas was considered significant to enhance service delivery and the psychosocial well-being of the learners. Overall, accountability was difficult to establish because the administration of psychosocial support is split among the Ministry of Education and Training, the Deputy Prime Minister’s office and Tinkhundla administration. There is unequal distribution of qualified early childhood development teachers to cater for early childhood educational needs.

HIV-sensitive social protection: an assessment of east and southern Africa’s social protection policies and programmes

2023-10-06T11:24:57+00:00

Despite notable political and financial commitment to fight the HIV epidemic, east and southern Africa (ESA) remains the world regions most affected. Given increasing calls for the implementation of HIV-sensitive social protection programmes to address the multiple individual, community and societal factors that heighten the risk of HIV infection, this article explores the extent to which social protection mechanisms in the region are HIV sensitive. The article is based on a two-phase project where the first phase entailed a desktop review of national social protection policies and programmes. In the second phase, multisectoral stakeholder consultations conducted were 15 fast-track countries in the region. The key findings suggest that social protection policies and social assistance programmes in ESA do not specifically target HIV issues or people living with, at risk of, or affected by HIV. Rather, and in line with the countries’ constitutional provisions, the programmes tend to be inclusive of the vulnerabilities of various populations including people living with HIV. To this end, the programmes can be seen as generally sufficient to encompass HIV-related issues and the needs of people infected and affected by the epidemic. However, a recurring argument from many stakeholders is that, to the extent that people living with HIV are often reluctant to either disclose their status and/or access social protection services, it is critical for social protection policies and programmes to be explicitly HIV sensitive. The article thus concludes by making recommendations in this regard as well as by making a class for multisectoral partners to work collaboratively to ensure that social protection policies and programmes are transformative.

Provider perspectives on antiretroviral therapy adherence among psychiatric inpatients in Botswana

2023-10-06T11:53:10+00:00

Background: Optimal adherence to antiretroviral therapy (ART) is crucial for the effective management of HIV. Mental disorders often co- occur with HIV infection which often compromises ART adherence. Little is known about ART adherence in psychiatric settings in sub-Saharan Africa.

Aims: This study aimed at exploring the health care providers’ perspectives on ART adherence among psychiatric inpatients. The study further assessed the facilitators and strategies enhancing ART adherence in hospitalised psychiatric patients.

Methods: In-depth interviews were conducted with 25 health care providers at the Sbrana Psychiatric Hospital in Botswana. Interviews were focused on barriers and facilitators to psychiatric inpatients’ adherence to ART, and strategies and recommendations to support adherence. Data were manually analysed using a thematic analysis approach.

Results: Key barriers were lack of insight, HIV-related stigma, lack of HIV- related knowledge, antiretroviral side effects and delays in re-initiating ART. Facilitators of ART adherence included motivation to be discharged from the hospital, fear of being sick, peer support, longer duration of hospitalisation, good provider-patient relationships, good diet, privacy and confidentiality and a single-tablet regimen. Health care providers described the various strategies currently used to support adherence, including directly observed therapy and family support, and recommended potential approaches to enhance psychiatric inpatient adherence to ART, including the use of injectable antiretrovirals and the introduction of halfway house centres.

Conclusions: Findings from this study revealed unique insights into the numerous factors that influence ART adherence among psychiatric inpatients, and underscore the need to implement tailored strategies to support ART adherence in this population with complex health needs.

Community health workers can be trained to identify patients eligible for tuberculosis preventive therapy, but encounter barriers to programme implementation in KwaZulu-Natal, South Africa

2023-10-06T12:24:53+00:00

Tuberculosis (TB) remains one of the top 10 causes of death worldwide, ranking as the leading cause of death from infectious disease, above HIV and AIDS. South Africa has the sixth highest TB incidence rate in the world and the world’s largest HIV epidemic. This study sought to demonstrate the feasibility of community health workers (CHWs) contributing to the implementation of tuberculosis preventive therapy (TPT) among people living with HIV and AIDS. Twelve community health workers were trained to test for communicable and non-communicable diseases and screen for TPT eligibility. They visited a select number of homes monthly to conduct screening for HIV, TB and non-communicable diseases. We recorded screening results, rates of referral for TPT, linkage to care — defined as being seen in the clinic for TPT — and treatment initiation. Among the 1 279 community members screened, 248 were identified as living with HIV, 99 (39.9%) individuals were identified as eligible for TPT, and 46 (46.5%) were referred to care. Among those referred, the median age was 39 (IQR 30-48) and 29 (63%) linked to care; 11 (37.9%) of those linked subsequently initiated treatment. In rural South Africa, it is feasible to train CHWs to identify and refer patients eligible for TPT, but losses occurred at each step of the cascade. CHWs can facilitate TPT implementation, although further implementation research exploring and addressing barriers to TPT (on an individual, provider and systems level) should be prioritised to optimise their role in rural resource-limited settings.

Early infant male circumcision: Potential for changing adverse gender norms associated with traditional male circumcision among circumcising communities in Kenya

2023-10-06T12:45:51+00:00

Introduction: Traditional male circumcision (TMC) inculcates masculine-dominance norms in young men. Early infant male circumcision (EIMC) and medical male circumcision (MMC) can potentially minimise these adverse gender norms. We explored the perceptions about EIMC and MMC among communities practising TMC in Kenya.

Method: We conducted focus group discussions with men and women and councils of elders, and key informant interviews with traditional circumcisers. Data were analysed using NVivo 10.

Results: Most participants described MC as a rite of passage into adulthood, with the preferred age for MC to occur at 10 to 15 years old. Interestingly, awareness of the advantages of EIMC, especially among younger men and women, was high. Participants acknowledged that TMC reinforces hegemonic masculinity that undermines gender equality. Except among traditional circumcisers and some members of councils of elders, MMC and female providers were largely deemed acceptable.

Conclusion: EIMC and MMC are slowly gaining acceptance, providing important tools to challenge adverse gender norms associated with TMC.