HIV-related mHealth interventions have demonstrable efficacy in supporting treatment adherence, although the evidence base for promoting HIV testing is inconclusive. Progress is constrained by a limited understanding of processes used to develop interventions and weak theoretical underpinnings. This paper describes a research project that informed the development of a theory-based mHealth intervention to promote HIV testing amongst city-dwelling African communities in the conditions. A community-based participatory social marketing design was adopted. Six focus groups (48 participants in total) were undertaken and analysed using a thematic framework approach, guided by constructs from the Health Belief Model. Key themes were incorporated into a set of text messages, which were pre-tested and refined. The focus groups identified a relatively low perception of HIV risk, especially amongst men, and a range of social and structural barriers to HIV testing. In terms of self-efficacy around HIV testing, respondents highlighted a need for communities and professionals to work together to build a context of trust through co-location in, and co-involvement of, local communities which would in turn enhance confidence in, and support for, HIV testing activities of health professionals. Findings suggested that messages should: avoid an exclusive focus on HIV, be tailored and personalised, come from a trusted source, allay fears and focus on support and health benefits. HIV remains a stigmatised and de-prioritised issue within African migrant communities in the UK, posing barriers to HIV testing initiatives. A community-based participatory social marketing design can be successfully used to develop a culturally appropriate text messaging HIV intervention. Key challenges involved turning community research recommendations into brief text messages of only 160 characters.
Equity and HIV/AIDS
This short film argues that many more people living with HIV in sub-Saharan Africa could be treated if laboratory tests were used in a targeted rather than routine way. Trial participants, practitioners and investigators explain how maintaining and scaling up access to antiretroviral therapy (ART) in low- and middle-income countries could be possible on current funding levels, even in the midst of a global economic crisis. The principal message from Developing Antiretroviral Therapy in Africa (DART) is that ART saves lives, and that it can be delivered safely and successfully without the use of routine laboratory testing for drug toxicity and side effects. Use of routine CD4 testing for monitoring disease progression is argued to offer only a small benefit to patients after the second year of therapy. Trial investigators believe that priority should be given to widening access to first- and second-line drugs to treat HIV, with resources focused on strengthening healthcare systems and training well-supervised healthcare workers to deliver quality care in rural areas.
The World Health Organisation recommends HIV-infected mothers exclusively breastfeed their infants, unless replacement feeding is Acceptable, Feasible, Affordable, Sustainable and Safe (AFASS). The aim of this study was to develop and content validate an AFASS assessment tool that could be used for infant feeding counselling in sub-Saharan Africa (SSA). An AFASS assessment tool consisting of 15 questions was developed based on the evidence and tools available regarding why replacement feeding is not AFASS in the region. Fifty-seven experts involved in prevention of mother-to-child HIV transmission (PMTCT) programmes in five SSA countries were approached to participate as members of the Delphi expert panel, reduced to a final panel of 15 experts. Thirteen of the 15 questions in the tool achieved consensus agreement among panel members and they also reached consensus regarding the applicability and appropriateness of the tool within the regional context. Suggestions made by the expert panel were incorporated into the revised tool. Ideally the revised tool should be tested by providers of infant feeding advice with the aim of adoption into routine PMTCT programmes in SSA, but within the context of the 2010 WHO guidelines which advocate a public health rather than an individualised approach, it may inform the WHO process of improving counselling tools for health care workers involved in PMTCT programmes.
This study assessed differences in access to antiretroviral treatment (ART) and patient outcomes across public sector treatment facilities in the Free State province, South Africa. It took the form of a prospective cohort study with retrospective database links. Data on patients enrolled in the treatment programme was analysed across 36 facilities between May 2004 and December 2007. Of 44,866 patients enrolled, 15,219 initiated treatment within one year, 8,778 died within one year (7,286 before accessing ART). Outcomes at one year varied greatly across facilities and more variability was explained by facility-level factors than by patient-level factors. The odds of starting treatment within one year improved over calendar time. Patients were less likely to start treatment if they were male, severely immunosuppressed, or underweight. Men were also more likely to die in the first year after enrolment. Although increasing numbers of patients started ART between 2004 and 2007, many patients died before accessing ART. Patient outcomes could be improved by decentralisation of treatment services, fast-tracking the most immunodeficient patients and improving access, especially for men.
Although South Africa is committed to providing anti-retroviral treatment (ART) to all South Africans who need it, there are insufficient pharmacists working in public sector facilities to dispense ART to all these patients, according to this policy brief, which means that dispensing tasks must be shifted to pharmacists assistants and/or nurses. The Health Economics Unit (HEU) argues that the pharmacists assistant pharmaceutical care model has the lowest cost to the health system and would support a more integrated primary health care service. Patients getting their ART by attending facilities staffed by pharmacists assistants and nurses experienced relatively better geographic access to facilities and lower transport costs, compared to those attending more central facilities that employ pharmacists. Patients prefer a nurse to dispense their ARTs as this reduces the risk of being identified by other patients as being HIV-positive. The pharmacists assistant model can be made more acceptable to patients by ensuring that there are no differences between patient folders (e.g. those on ART should not have differently coloured folders) and dispensing all medication (not only anti-retrovirals) in brown paper bags.
This study took the form of a systematic review and meta-analysis of randomised trials of directly observed versus self-administered antiretroviral treatment. Duplicate searches of databases were conducted, as well as searchable websites of major HIV conferences and lay publications and websites, to identify randomised trials assessing directly observed therapy to promote adherence to antiretroviral therapy in adults. Twelve studies met the inclusion criteria. Four of these were done in groups that were judged to be at high risk of poor adherence (drug users and homeless people). Ten studies reported on the primary outcome – the study calculated a pooled relative risk of 1.04, and noted moderate heterogeneity between the studies for directly observed versus self-administered treatment. The study found that directly observed antiretroviral therapy seems to offer no benefit over self-administered treatment, which calls into question the use of such an approach to support adherence in the general patient population.
This study presents the experiences of a cohort of 17 patients enrolled in the first integrated TB and HIV treatment pilot programme, in Durban, South Africa, as a precursor to a pivotal trial to answer the question of when to start antiretroviral treatment (ART) in patients co-infected with HIV and TB. Individual interviews, focus group discussions, and observations were used to understand patients’ experiences with integrated TB and HIV treatment. The patients described incorporating highly active antiretroviral therapy (HAART) into their daily routine as ‘easy’; however, they experienced difficulties with disclosing their HIV status. Being on TB treatment created a safe space for all patients to conceal their HIV status from those to whom they did not wish to disclose. Directly observed therapy for TB may have the added benefit of creating a safe space for introducing ART to patients who are not ready to disclose their HIV+ status.
Oxfam and Médecins Sans Frontières (MSF) welcome Abbott’s decision to offer developing countries a further 55% reduction of its price for Kaletra/Aluvia, a key HIV medicine. However, Oxfam and MSF will continue to support the Thailand government in maintaining its compulsory licenses as an alternative channel for accessing affordable life-saving medicines. As a next step Abbott should publish a comprehensive list of all countries eligible for the price cut.
This paper explored the health-system resilience at the sub-national level in Uganda with regard to strategies for dispensing antiretrovirals during Covid-19 lockdown. The authors conducted a qualitative case-study of eight districts purposively selected from Eastern and Western Uganda. Between June and September 2020, through interviews with district health team leaders, ART clinic managers, representatives of PEPFAR implementing organizations and focus group discussions with recipients of HIV care. Five broad strategies for distributing antiretrovirals during ‘lockdown’ emerged: (i) accelerating home-based delivery of antiretrovirals; (ii) extending multi-month dispensing from three to six months for stable patients; (iii) leveraging the Community Drug Distribution Points model for ART refill pick-ups at outreach sites in the community; (iv) increasing reliance on health information systems, including geospatial technologies, to support ART refill distribution in unmapped rural settings and (v) leveraging Covid-19 outbreak response funding to deliver ART refills to rural homesteads. While Covid-19 ‘lockdown’ restrictions undoubtedly impeded access to facility-based HIV services, they revived interest by providers and demand by patients for community-based ART delivery models in case-study districts in Uganda.
A comprehensive care and treatment program requires a well functioning laboratory services. This study assessed satisfaction of medical personnel to the laboratory services to guide process of quality improvement of the services. A cross-sectional survey in 24 randomly selected health facilities in Mainland Tanzania was conducted to assess the satisfaction of the medical personnel with the laboratory services. About one quarter of medical personnel in sending or receiving laboratories were dissatisfied with the services. Comparing the personnel in public and private, the personnel in public laboratories were 4 times more dissatisfied with the timely test and correct results; and 5 times more dissatisfied with clear and complete test results.