Community-supported models of care for people on HIV treatment in sub-Saharan Africa.

OBJECTIVES: Further scale-up of antiretroviral therapy (ART) to those in need while supporting the growing patient cohort on ART requires continuous adaptation of healthcare delivery models. We describe several approaches to manage stable patients on ART developed by Médecins Sans Frontières together with Ministries of Health in four countries in sub-Saharan Africa. METHODS: Using routine programme data, four approaches to simplify ART delivery for stable patients on ART were assessed from a patient and health system perspective: appointment spacing for clinical and drug refill visits in Malawi, peer educator-led ART refill groups in South Africa, community ART distribution points in DRC and patient-led community ART groups in Mozambique. RESULTS: All four approaches lightened the burden for both patients (reduced travel and lost income) and health system (reduced clinic attendance). Retention in care is high: 94% at 36 months in Malawi, 89% at 12 months in DRC, 97% at 40 months in South Africa and 92% at 48 months in Mozambique. Where evaluable, service provider costs are reported to be lower. CONCLUSION: Separating ART delivery from clinical assessments was found to benefit patients and programmes in a range of settings. The success of community ART models depends on sufficient and reliable support and resources, including a flexible and reliable drug supply, access to quality clinical management, a reliable monitoring system and a supported lay workers cadre. Such models require ongoing evaluation and further adaptation to be able to reach out to more patients, including specific groups who may be challenged to meet the demands of frequent clinic visits and the integrated delivery of other essential chronic disease interventions.

Factors Related to Police Reporting in Sexual Assault Care Centers: Are We Underestimating the Role of Support Persons?

Few victims of sexual assault (SA) report to the police. Research on the role of support persons in victims' reporting is sparse. We address this gap by examining the association of victim, assailant, victimization incident, and support characteristics with reporting rates among victims attending sexual assault care centers (SACCs). Logistic regression results show that type of SA, delay between SA and presentation at SACC, and presence of an informal support person at SACC and SACC site are significantly associated with police reporting. These findings reveal the importance of targeting victims' support persons to alter reporting behavior among SA victims.

Mental health of sexual assault victims and predictors of their use of support from in-house psychologists at Belgian sexual assault care centres.

BACKGROUND: Sexual assault (SA) can induce a negative impact on victims' mental health. Specialised SA services generally offer medical care and a forensic examination to SA victims. However, there is a large variation in how these services provide mental health support. OBJECTIVE: This study aims to assess mental health problems of SA victims attending the Belgian Sexual Assault Care Centres (SACCs) and identify predictors for victims' use of support from in-house psychologists. METHOD: Health records of victims ≥ 16 years who presented within one week post-SA to one of the three Belgian SACCs between 25 October 2017 and 31 October 2019 were reviewed. An AIC-based stepwise backward binary logistic regression was used to analyse the association between victim, assault, service use and mental health characteristics and follow-up by a SACC-psychologist. RESULTS: Of the 555 victims, more than half had a history of mental health problems. Of those assessed, over 70% showed symptoms of posttraumatic stress disorder (PTSD), depression and/or anxiety disorder. One in two victims consulted a SACC-psychologist. Victims with a mental health history (OR 1.46, p = .04), victims accompanied by a support person during acute care (OR 1.51, p = .04), and victims who were assaulted by an acquaintance in comparison to those assaulted by a stranger (OR 1.60, p = .039) were more likely to attend their appointment with the SACC-psychologist. CONCLUSION: The study reaffirms the high mental health burden among victims attending specialised SA services, stressing the need to provide effective mental health interventions at these services and improve their longer-term use by victims. Prescheduling of appointments with an in-house psychologist in combination with phone reminders may improve the uptake of such services. Health care providers must be vigilant about potential barriers faced by victims without a mental health history or social support in attending appointments with mental health professionals.

The mental health burden is high among victims attending Belgian Sexual Assault Care Centres.Half of the victims use the support of an in-house psychologist. Victims with a history of mental health problems, those accompanied by a support person during acute care, and those assaulted by an acquaintance in comparison to those assaulted by a stranger, are more likely to use this support.Effective mental health support should be recognised as an integral and essential part of care for SA victims. Uptake and longer-term engagement with this mental health support should be improved for those victims diagnosed with PTSD.

Piloting sexual assault care centres in Belgium: who do they reach and what care is offered?

Background: Sexual assault (SA) is highly prevalent in Belgium. In order to mitigate the negative consequences for victims of acute SA, Sexual Assault Care Centres (SACCs) were piloted from October 2017 to October 2018 in three Belgian hospitals. SACCs offer medical and psychological care, forensic examination and the possibility to report to the police at the SACC. Objective: Aiming to improve SACC services, we quantitatively assessed the number and characteristics of victims attending the SACC, the SA they experienced, and the care they received over 12 months upon admission. Method: Data on victims presenting at the SACC were routinely collected in electronic patient files by the SACC personnel between 25 October 2017 and 31 October 2019. These data were analysed in IBM SPSS Statistics 25. Results: Within the first year 931 victims attended the SACCs. Mean age was 24.5 years (SD = 12.8), and one-third were under 18. The majority were female (90.5%) and 63.1% presented for rape. About one-third of the victims were considered vulnerable due to previous SA (35.6%), prior psychiatric consultation (38.7%) or disability (8.5%). The assailant was known to the victim in 59.2% of the cases. Of all SACC presentations, 35.2% self-referred to the SACC while 40.9% were referred by the police. Two out of three victims attended the SACC within 72 h post-assault. Respectively 74.7% of victims received medical care, 60.6% a forensic examination, 50.2% psychological care, and 68.7% reported to the police. Conclusion: Despite the absence of promotion campaigns, the SACCs received a high number of victims during the pilot year. Use of acute and follow-up services was high, although new approaches to offer more accessible psychological support should be explored. The big proportion of vulnerable victims warrants careful monitoring and adaptation of care pathways.

Antecedentes: El asalto sexual (SA en si sigla en inglés) es altamente prevalente en Bélgica. Para mitigar las consecuencias negativas para las víctimas de SA agudo, los Centros de Atención de Asalto Sexual (SACCs en su sigla en inglés) fueron piloteados desde octubre de 2017 hasta octubre 2018 en tres hospitales belgas. Los SACCs ofrecen atención médica y psicológica, examen forense y la posibilidad de reportar a la policía en el SACC.Objetivo: Para mejorar los servicios SACC, medimos cuantitativamente el número y las características de las víctimas atendidas por el SACC, el SA que experimentaron y la atención que recibieron a lo largo de los 12 meses desde su admisión.Método: Fueron recolectados rutinariamente los datos en las víctimas que se presentaron en el SACC por el personal de SACC en los archivos electrónicos de los pacientes entre el 25 de octubre 2017 y 31 de octubre de 2019. Estos datos fueron analizados en el Programa Estadístico IBM SPSS 25.Resultados: Dentro del primer año, 931 victimas asistieron a los SCCs. La edad media fue 24,5 (DE = 12.8), y un tercio eran menores de 18 años. La mayoría eran mujeres (90.5%) y 63.1% se presentaron por violación. Alrededor de un tercio de las víctimas fueron consideradas vulnerables debido a SA previos (35.6%), consulta psiquiátrica anterior (38.7%) o discapacidad (8.5%). El asaltante era un conocido de la víctima en 59.2% de los casos. De todas las presentaciones SACC, el 35.2% se autoderivaron a SACC, mientras que 40.9% fueron derivados por la policía. Dos de cada tres víctimas asistieron al SACC dentro de las primeras 72 horas luego del asalto. Respectivamente, el 74.7% de las víctimas recibieron atención médica, el 60.6% un examen forense, el 50.2% atención psicológica, y el 68.7% reportaron a la policía.Conclusión: A pesar de la ausencia de campañas de promoción, los SACCs recibieron un gran número de víctimas durante el año piloto. El uso de servicios agudos y de seguimiento fueron altos, aunque nuevas perspectivas para ofrecer más apoyo psicológico más accesible deberían ser exploradas. La mayor proporción de víctimas vulnerables garantiza un monitoreo cuidadoso y la adaptación de las vías de atención.

"We are part of a family". Benefits and limitations of community ART groups (CAGs) in Thyolo, Malawi: a qualitative study.

INTRODUCTION: In 2012 Community ART Groups (CAGs), a community-based model of antiretroviral therapy (ART) delivery were piloted in Thyolo District, Malawi as a way to overcome patient barriers to accessing treatment, and to decrease healthcare workers' workload. CAGs are self-formed groups of patients on ART taking turns to collect ART refills for all group members from the health facility. We conducted a qualitative study to assess the benefits and challenges of CAGs from patients' and healthcare workers' (HCWs) perspectives. METHODS: Data were collected by means of 15 focus group discussions, 15 individual in-depth interviews, and participant observation in 2 health centres. The 94 study participants included CAG members, ART patients eligible for CAGs who remained in conventional care, former CAG members who returned to conventional care and HCWs responsible for providing HIV care. Patient participants were purposively selected from ART registers, taking into account age and gender. Narratives were audio-recorded, transcribed, and translated from Chichewa to English. Data were analyzed through a thematic analysis. RESULTS: Patients and HCWs spoke favourably about the practical benefits of CAGs. Patient benefits included a reduced frequency of clinic visits, resulting in reduced transportation costs and time savings. HCW benefits included a reduced workload. Additionally peer support was perceived as an added value of the groups allowing not only sharing of the logistical constraints of drugs refills, but also enhanced emotional support. Identified barriers to joining a CAG included a lack of information on CAGs, unwillingness to disclose one's HIV status, change of residence and conflicts among CAG members. Participants reported that HIV-related stigma persists and CAGs were seen as an effective strategy to reduce exposure to discriminatory labelling by community members. CONCLUSION: In this setting, patients and HCWs perceived CAGs to be an acceptable model of ART delivery. Despite addressing important practical barriers to accessing ART, and providing peer support, CAGs were not well known by patients and had a limited impact on reducing HIV-related stigma. The CAG model of ART delivery should be considered in similar settings. Further measures need to be devised and implemented to address HIV-related stigma.

"They just come, pick and go." The Acceptability of Integrated Medication Adherence Clubs for HIV and Non Communicable Disease (NCD) Patients in Kibera, Kenya.

INTRODUCTION: The number of people on antiretroviral therapy (ART) for the long-term management of HIV in low- and middle-income countries (LMICs) is continuing to increase, along with the prevalence of Non-Communicable Diseases (NCDs). The need to provide large volumes of HIV patients with ART has led to significant adaptations in how medication is delivered, but access to NCD care remains limited in many contexts. Medication Adherence Clubs (MACs) were established in Kibera, Kenya to address the large numbers of patients requiring chronic HIV and/or NCD care. Stable NCD and HIV patients can now collect their chronic medication every three months through a club, rather than through individual clinic appointments. METHODOLOGY: We conducted a qualitative research study to assess patient and health-care worker perceptions and experiences of MACs in the urban informal settlement of Kibera, Kenya. A total of 106 patients (with HIV and/or other NCDs) and health-care workers were purposively sampled and included in the study. Ten focus groups and 19 in-depth interviews were conducted and 15 sessions of participant observation were carried out at the clinic where the MACs took place. Thematic data analysis was conducted using NVivo software, and coding focussed on people's experiences of MACs, the challenges they faced and their perceptions about models of care for chronic conditions. RESULTS: MACs were considered acceptable to patients and health-care workers because they saved time, prevented unnecessary queues in the clinic and provided people with health education and group support whilst they collected their medication. Some patients and health-care workers felt that MACs reduced stigma for HIV positive patients by treating HIV as any other chronic condition. Staff and patients reported challenges recruiting patients into MACs, including patients not fully understanding the eligibility criteria for the clubs. There were also some practical challenges during the implementation of the clubs, but MACs have shown that it is possible to learn from ART provision and enable stable HIV and NCD patients to collect chronic medication together in a group. CONCLUSIONS: Extending models of care previously only offered to HIV-positive cohorts to NCD patients can help to de-stigmatise HIV, allow for the efficient clinical management of co-morbidities and enable patients to benefit from peer support. Through MACs, we have demonstrated that an integrated approach to providing medication for chronic diseases including HIV can be implemented in resource-poor settings and could thus be rolled out in other similar contexts.

The uncertain future of lay counsellors: continuation of HIV services in Lesotho under pressure.

Between 2006 and 2011, when antiretroviral therapy (ART) was scaled up in a context of severe human resources shortages, transferring responsibility for elements in human immunodeficiency virus (HIV) care from conventional health workers to lay counsellors (LCs) contributed to increased uptake of HIV services in Lesotho. HIV tests rose from 79 394 in 2006 to 274 240 in 2011 and, in that same period, the number of people on ART increased from 17 352 to 83 624. However, since 2012, the jobs of LCs have been at risk because of financial and organizational challenges. We studied the role of LCs in HIV care in Lesotho between 2006 and 2013, and discuss potential consequences of losing this cadre. Methods included a case study of LCs in Lesotho based on: (1) review of LC-related health policy and planning documents, (2) HIV programme review and (3) workload analysis of LCs. LCs are trained to provide HIV testing and counselling (HTC) and ART adherence support. Funded by international donors, 487 LCs were deployed between 2006 and 2011. However, in 2012, the number of LCs decreased to 165 due to a decreasing donor funds, while administrative and fiscal barriers hampered absorption of LCs into the public health system. That same year, ART coverage decreased from 61% to 51% and facility-based HTC decreased by 15%, from 253 994 in 2011 to 215 042 tests in 2012. The workload analysis indicated that LCs work averagely 77 h per month, bringing considerable relief to the scarce professional health workforce. HIV statistics in Lesotho worsened dramatically in the recent era of reduced support to LCs. This suggests that in order to ensure access to HIV care in an under-resourced setting like Lesotho, a recognized and well-supported counsellor cadre is essential. The continued presence of LCs requires improved prioritization, with national and international support.

Sustaining the future of HIV counselling to reach 90-90-90: a regional country analysis.

INTRODUCTION: Counselling services are recommended by the World Health Organization and have been partially adopted by national HIV guidelines. In settings with a high HIV burden, patient education and counselling is often performed by lay workers, mainly supported with international funding. There are few examples where ministries of health have been able to absorb lay counsellors into their health systems or otherwise sustain their work. We document the role of lay cadres involved in HIV testing and counselling and adherence support and discuss approaches to sustainability. METHODS: We focused on a purposive sample of eight sub-Saharan African countries where Médecins Sans Frontières supports HIV programmes: Guinea, Lesotho, Malawi, Mozambique, South Africa, Swaziland, Zambia and Zimbabwe. We reviewed both published and grey literature, including national policies and donor proposals, and interviewed key informants, including relevant government staff, donors and non-governmental organizations. RESULTS AND DISCUSSION: Lay counsellors play a critical role in scaling up HIV services and addressing gaps in the HIV testing and treatment cascade by providing HIV testing and counselling and adherence support at both the facility and community levels. Countries have taken various steps in recognizing lay counsellors, including harmonizing training, job descriptions and support structures. However, formal integration of this cadre into national health systems is limited, as lay counsellors are usually not included in national strategies or budgeting. CONCLUSIONS: The current trend of reduced donor support for lay counsellors, combined with lack of national prioritization, threatens the sustainability of this cadre and thereby quality HIV service delivery.

Outcomes from the implementation of a counselling model supporting rapid antiretroviral treatment initiation in a primary healthcare clinic in Khayelitsha, South Africa.

BACKGROUND: Lengthy antiretroviral treatment (ART) preparation contributes to high losses to care between communicating ART eligibility and initiating ART. To address this shortfall, Médecins Sans Frontières implemented a revised approach to ART initiation counselling preparation (integrated for TB co-infected patients), shifting the emphasis from pre-initiation sessions to addressing common barriers to adherence and strengthening post-initiation support in a primary healthcare facility in Khayelitsha, South Africa. METHODS: An observational cohort study was conducted using routinely collected data for all ART-eligible patients attending their first counselling session between 23 July 2012 and 30 April 2013 to assess losses to care prior to and post ART initiation. Viral load completion and suppression rates of those retained on ART were also calculated. RESULTS: Overall, 449 patients enrolled in the study, of whom 3.6% did not return to the facility to initiate ART. Of those who were initiated, 96.7% were retained at their first ART refill visit and 85.9% were retained 6 months post ART initiation. Of those retained, 80.2% had a viral load taken within 6 months of initiating ART, with 95.4% achieving viral load suppression. CONCLUSIONS: Adapting counselling to enable rapid ART initiation is feasible and has the potential to reduce losses to care prior to ART initiation without increasing short-term losses thereafter or compromising patient adherence.