Barriers and facilitators to uptake and persistence on prep among key populations in Southern Province, Zambia: a thematic analysis.

BACKGROUND: Especially in high HIV prevalence contexts, such as Zambia, effective biomedical prevention tools are needed for priority populations (PPs), including key populations (KPs), who are at higher risk. HIV pre-exposure prophylaxis (PrEP) has been scaled up nationally in Zambia, but little is known about barriers to PrEP use among specific PPs to date. METHODS: To understand barriers and facilitators to PrEP use in Zambia, we conducted a qualitative case study of PrEP services to PPs including sero-discordant couples (SDCs), female sex workers (FSWs), and men who have sex with men (MSM) in Livingstone. The study conducted in 2021 included in-depth interviews (n = 43) guided by the socio-ecological model, and focus group discussions (n = 4) with clinic and community-based providers and PrEP-eligible clients including users and non-users across PP groups. We used thematic analysis to analyze data using codes derived both deductively and inductively. RESULTS: We found multilevel barriers and facilitators to PrEP use. Cross-cutting barriers shared across PP groups included amplifying effects of PrEP being mistaken for antiretroviral drugs used to treat HIV, including anticipated stigma, and concerns about side-effects based on both misinformation and experience. In addition, stigmatized identities, particularly that of MSM, served as a barrier to PrEP use. The fear of being mislabeled as having HIV was of greatest concern for FSWs. Facilitators to PrEP use primarily included the importance of confidential, KP-sensitive services, and the role of informed, supportive family, friends, and peers. Participants across all PP groups urged expanded education efforts to increase awareness of PrEP within the general population toward mitigating concerns of being mislabeled as living with HIV. CONCLUSION: To our knowledge, this is the first qualitative study of the PrEP cascade among multiple PPs in Zambia. This study provides important explanation for the low rates of PrEP continuation found in earlier demonstration trials among KPs in Zambia. The study also offers recommendations for programming efforts going forward such as inclusive PrEP awareness campaigns, expanded KP sensitivity training, and related efforts to thwart PrEP stigma while expanding access.

Effects of Multimonth Dispensing on Viral Suppression and Continuity in Treatment Among Children Living With HIV Aged 2-9 Years: A Cohort Study in Western Kenya.

BACKGROUND: In Kenya, of the 82,000 children living with HIV, only 59% are receiving ART and 67% are virally suppressed. Early in the COVID-19 pandemic, the Ministry of Health recommended 3 multimonth dispensing (3MMD) of ART to all people living with HIV, including children. This study assesses the association between 3 MMD and clinical outcomes among children in Western Kenya. SETTINGS: and Methods: We conducted a retrospective cohort study using routinely collected deidentified patient-level data from 43 facilities in Kisii and Migori Counties. The study included children aged 2-9 years who had been previously initiated on ART and sought HIV services between March 01, 2020, and March 30, 2021. We used generalized linear models with Poisson regression models to assess the association between MMD on retention at 6 months and viral suppression (<1000 copies/mL). RESULTS: Among the 963 children, 65.2% were aged 5-9 years and 50.7% were female patients. Seventy-eight percent received 3MMD at least once during the study period. Children who received 3MMD were 12% (adjusted risk ratio [aRR] 1.12, 95% CI: 1.01 to 1.24) more likely to be retained and 22% (aRR 1.22, 1.12 to 1.34) more likely to be virally suppressed than those on <3MMD. When stratified by viral suppression at entry, the association between 3MMD and retention (aRR 1.22, 95% CI: 1.02 to 1.46) and viral suppression (aRR 1.76, 95% CI: 1.30-2.37) was significant among individuals who were unsuppressed at baseline. CONCLUSIONS: 3MMD was associated with comparable or improved HIV health outcomes among children.

Person-centred interventions to improve patient-provider relationships for HIV services in low- and middle-income countries: a systematic review.

INTRODUCTION: Person-centred care (PCC) has been recognized as a critical element in delivering quality and responsive health services. The patient-provider relationship, conceptualized at the core of PCC in multiple models, remains largely unexamined in HIV care. We conducted a systematic review to better understand the types of PCC interventions implemented to improve patient-provider interactions and how these interventions have improved HIV care continuum outcomes and person-reported outcomes (PROs) among people living with HIV in low- and middle-income countries. METHODS: We searched databases, conference proceedings and conducted manual targeted searches to identify randomized trials and observational studies published up to January 2023. The PCC search terms were guided by the Integrative Model of Patient-Centeredness by Scholl. We included person-centred interventions aiming to enhance the patient-provider interactions. We included HIV care continuum outcomes and PROs. RESULTS: We included 28 unique studies: 18 (64.3%) were quantitative, eight (28.6.%) were mixed methods and two (7.1%) were qualitative. Within PCC patient-provider interventions, we inductively identified five categories of PCC interventions: (1) providing friendly and welcoming services; (2) patient empowerment and improved communication skills (e.g. supporting patient-led skills such as health literacy and approaches when communicating with a provider); (3) improved individualized counselling and patient-centred communication (e.g. supporting provider skills such as training on motivational interviewing); (4) audit and feedback; and (5) provider sensitisation to patient experiences and identities. Among the included studies with a comparison arm and effect size reported, 62.5% reported a significant positive effect of the intervention on at least one HIV care continuum outcome, and 100% reported a positive effect of the intervention on at least one of the included PROs. DISCUSSION: Among published HIV PCC interventions, there is heterogeneity in the components of PCC addressed, the actors involved and the expected outcomes. While results are also heterogeneous across clinical and PROs, there is more evidence for significant improvement in PROs. Further research is necessary to better understand the clinical implications of PCC, with fewer studies measuring linkage or long-term retention or viral suppression. CONCLUSIONS: Improved understanding of PCC domains, mechanisms and consistency of measurement will advance PCC research and implementation.