Negative clinic experiences as a barrier to care for people with HIV and their impact on patient preferences for intervention support: a qualitative study in Cape Town, South Africa.

We conducted qualitative research among people with HIV (PWH) and care providers in Cape Town, South Africa to understand the impact of negative clinic experiences on adherence and support preferences. In-depth interviews were conducted with 41 patients with an unsuppressed viral load or a treatment gap, and focus group discussions with physicians, nurses, counselors, and community health workers. Questions addressed treatment history and adherence barriers, then participants evaluated evidence-based adherence interventions for potential scale up. Inductive analysis examined care experiences and corresponding preference for intervention options. More than half of PWH described negative experiences during clinic visits, including mistreatment by staff and clinic administration issues, and these statements were corroborated by providers. Those with negative experiences in care stated that fear of mistreatment led to nonadherence. Most patients with negative experiences preferred peer support groups or check-in texts to clinic-based interventions. We found that PWH's negative clinic experiences were a primary reason behind nonadherence and influenced preferences for support mechanisms. These findings emphasize the importance of HIV treatment adherence interventions at multiple levels both in and outside of the clinic, and providing more comprehensive training to providers to better serve PWH in adherence counseling, especially those who are most vulnerable..

The effects of revised peer-counselor support on the PMTCT cascade of care: results from a cluster-randomized trial in Kenya (the EMMA study).

BACKGROUND: This study evaluated the effect of revisions to existing peer-counselor services, called Mentor Mothers (MM), at maternal and child health clinics on medication adherence for women living with HIV (WLWH) in Kenya and on early infant HIV testing. METHODS: The Enhanced Mentor Mother Program study was a 12-site, two-arm cluster-randomized trial enrolling pregnant WLWH from March 2017 to June 2018 (with data collection through September 2020). Six clinics were randomized to continued MM-supported standard care (SC). Six clinics were randomized to the intervention arm (INT = SC plus revised MM services to include more one-on-one interactions). Primary outcomes for mothers were defined as: (PO1) the proportion of days covered (PDC) with antiretroviral therapy (ART) ≥ 0.90 during the last 24-weeks of pregnancy; and (PO2) ≥ 0.90 PDC during the first 24-weeks postpartum. Secondary outcomes were infant HIV testing according to national guidelines (at 6, 24, and 48 weeks). Crude and adjusted risk differences between study arms are reported. RESULTS: We enrolled 363 pregnant WLHV. After excluding known transfers and subjects with incomplete data extraction, data were analyzed for 309 WLWH (151 SC, 158 INT). A small share achieved high PDC during the prenatal and postnatal periods (0.33 SC/0.24 INT achieved PO1; 0.30 SC/0.31 INT achieved PO2; crude or adjusted risk differences were not statistically significant). In addition, ~ 75% in both study arms completed viral load testing during year two after enrollment, with > 90% suppressed in both arms. For infants, ≥ 90% in both arms had at least one HIV test through study follow up (76 weeks) but testing on schedule according to PMTCT guidelines was uncommon. CONCLUSIONS: While national guidelines in Kenya recommended that all HIV-infected pregnant women take a daily antiretroviral regimen for life following a HIV diagnosis, results presented here indicate that a minor share achieved high medication coverage during the prenatal and postnatal periods analyzed. In addition, adjustments to Mentor-Mother services showed no improvement in study outcomes. The lack of effect for this behavioral intervention is relatively consistent with the existing literature to improve mother-infant outcomes along the PMTCT care cascade. CLINICAL TRIAL NUMBER: NCT02848235. Date of first trial registration 28/07/2016.

Patients' and Providers' Views on Optimal Evidence-Based and Scalable Interventions for Individuals at High Risk of HIV Treatment Failure: Sequential Explorations Among Key Stakeholders in Cape Town, South Africa.

To support translation of evidence-based interventions into practice for HIV patients at high risk of treatment failure, we conducted qualitative research in Cape Town, South Africa. After local health officials vetted interventions as potentially scalable, we held 41 in-depth interviews with patients with elevated viral load or a 3-month treatment gap at community clinics, followed by focus group discussions (FGDs) with 20 providers (physicians/nurses, counselors, and community health care workers). Interviews queried treatment barriers, solutions, and specific intervention options, including motivational text messages, data-informed counseling, individual counseling, peer support groups, check-in texts, and treatment buddies. Based on patients' preferences, motivational texts and treatment buddies were removed from consideration in subsequent FGDs. Patients most preferred peer support groups and check-in texts while individual counseling garnered the broadest support among providers. Check-in texts, peer support groups, and data-informed counseling were also endorsed by provider sub-groups. These strategies warrant attention for scale-up in South Africa and other resource-constrained settings.

Real-time Feedback to Improve HIV Treatment Adherence in Pregnant and Postpartum Women in Uganda: A Randomized Controlled Trial.

We assessed an intervention aimed at improving adherence to antiretroviral therapy (ART) among pregnant and postpartum women living with HIV (PPWLH). We randomized 133 pregnant women initiating ART in Uganda to receive text reminders generated by real time-enabled electronic monitors and data-informed counseling through 3 months postpartum (PPM3) or standard care. Intention-to-treat analyses found low adherence levels and no intervention impact. Proportions achieving ≥95% adherence in PPM3 were 16.4% vs. 9.1% (t = -1.14, p = 0.26) in intervention vs. comparison groups, respectively; 30.9% vs. 29.1% achieved ≥80% adherence. Additional analyses found significant adherence declines after delivery, and no effect on disease progression (CD4-cell count, viral load), though treatment interruptions were significantly fewer in intervention participants. Per-protocol analyses encompassing participants who used adherence monitors as designed experienced better outcomes, suggesting potential benefit for some PPWLH. The study was registered on ClinicalTrials.Gov (NCT02396394).

Violence, HIV Risks, and Polysubstance Use Among HIV-Positive People Who Inject Drugs in Ukraine.

Violence experience has been consistently associated with HIV risks and substance use behaviors. Although many studies have focused on intimate partner violence (IPV), the role of violence at a structural level (i.e., police abuse) remains relevant for people who inject drugs. This study evaluated the association of IPV and police-perpetrated violence experiences with HIV risk behaviors and substance use in a cohort of HIV-positive people who inject drugs in Ukraine. We also evaluated possible moderation effects of gender and socioeconomic status in the links between violence exposure and HIV risk and polysubstance use behaviors. Data came from the Providence/Boston-CFAR-Ukraine Study involving 191 HIV-positive people who inject drugs conducted at seven addiction treatment facilities in Ukraine. Results from logistic regressions suggest that people who inject drugs and experienced IPV had higher odds of polysubstance use than those who did not experience IPV. Verbal violence and sexual violence perpetrated by police were associated with increased odds of inconsistent condom use. The odds of engaging in polysubstance use were lower for women in relation to police physical abuse. We found no evidence supporting socioeconomic status moderations. Violence experiences were associated with substance use and sexual HIV risk behaviors in this cohort of HIV-positive people who inject drugs in Ukraine. Trauma-informed prevention approaches that consider both individual and structural violence could improve this population's HIV risks.

RESUMEN: La experiencia de violencia se ha asociado sistemáticamente con las conductas de riesgo para la adquisición o transmisión del VIH y con el uso de sustancias. Aunque muchos estudios se han centrado en la violencia infligida por la pareja íntima (VPI), el papel de la violencia estructural (es decir, el abuso policial) sigue siendo relevante para las personas que se inyectan drogas. Este estudio evaluó la asociación entre las experiencias de violencia perpetrada por la policía y la pareja íntima con los conductas de riesgo para la adquisición o transmisión del VIH y el uso de sustancias en una cohorte de personas VIH positivas que se inyectan drogas en Ucrania. También evaluamos los posibles efectos de moderación del género y el estatus socioeconómico entre la exposición a la violencia y los comportamientos de riesgo para la transmisión del VIH y uso de múltiples sustancias. Los datos provienen del estudio Providence / Boston-CFAR-Ucrania en el que participaron 191 personas infectadas por el VIH que se inyectan drogas, realizado en siete centros de tratamiento de adicciones en Ucrania. Los resultados de las regresiones logísticas sugieren que, en comparación con las personas que se inyectan drogas que no experimentaron IPV, las que experimentaron IPV tenían mayor probabilidad de uso de múltiples sustancias. La violencia sexual perpetrada por la policía se asoció con mayores probabilidades de un uso inconsistente del condón. No encontramos evidencia que apoye las moderaciones de género o estatus socioeconómico. Las experiencias de violencia se asociaron con el uso de sustancias y las conductas sexuales de riesgo para la transmisión del VIH en esta cohorte de personas VIH positivas que se inyectan drogas en Ucrania. Los enfoques de prevención basados en las experiencias traumáticas que tienen en cuenta tanto la violencia individual como la estructural podrían mejorar las conductas de riesgo para la transmission del VIH de esta población.

Retention in HIV Care Among HIV-Seropositive Pregnant and Postpartum Women in Uganda: Results of a Randomized Controlled Trial.

We tested an intervention that aimed to increase retention in antiretroviral therapy (ART) among HIV-positive pregnant and postpartum women, a population shown to be vulnerable to poor ART outcomes. 133 pregnant women initiating ART at 2 hospitals in Uganda used real time-enabled wireless pill monitors (WPM) for 1 month, and were then randomized to receive text message reminders (triggered by late dose-taking) and data-informed counseling through 3 months postpartum or standard care. We assessed "full retention" (proportion attending all monthly clinic visits and delivering at a study facility; "visit retention" (proportion of clinic visits attended); and "postpartum retention" (proportion retained at 3 months postpartum). Intention-to-treat and per protocol analyses found that retention was relatively low and similar between groups, with no significant differences. Retention declined significantly post-delivery. The intervention was unsuccessful in this population, which experiences suboptimal ART retention and is in urgent need of effective interventions.

Facilitators and Barriers to Adherence to Antiretroviral Therapy and Retention in Care Among Adolescents Living with HIV/AIDS in Zambia: A Mixed Methods Study.

Little is known about the factors that contribute to the losses during stages of the HIV continuum of care (CoC) and specifically during the latter stages of antiretroviral (ART) adherence and retention in HIV care among adolescents living with HIV/AIDS (ALHA) in sub-Saharan Africa. We conducted a mixed-methods study: six focus group discussions with 43 ALHA (age 17-19); in-depth interviews with four (age 18-19): and survey-based interviews with 330 ALHA (age 18-19) to identify, understand, and describe factors contributing to the losses in the latter stages of the CoC among ALHA in Zambia. Through focus group discussions and in-depth interviews, ALHA identified barriers at the intrapersonal level (e.g., poverty; lack of adequate nutrition; fear of stigma), interpersonal level (e.g., stigma; disrespectful treatment by providers), institutional/facility level (e.g., lack of adolescent specific services), and community level (e.g., lack of collaboration among organizations; social norms). In quantitative interviews, we found that 46% (101/220) of ALHA reported missing any clinic appointments in the past three months, and about 19% (41/221) reporting missing one or more doses of ART in the last week. Logistic regressions indicate that walking to the site of appointment and being currently employed were predictive of missed visits. Findings highlight the complexity of the multiple factors that are unique to ALHA in Zambia, which should be addressed to improve adherence to ART and retention in HIV.

Effectiveness of community outreach HIV prevention programs in Vietnam: a mixed methods evaluation.

BACKGROUND: In 2014, Vietnam was the first Southeast Asian country to commit to achieving the World Health Organization's 90-90-90 global HIV targets (90% know their HIV status, 90% on sustained treatment, and 90% virally suppressed) by 2020. This pledge represented further confirmation of Vietnam's efforts to respond to the HIV epidemic, one feature of which has been close collaboration with the U.S. President's Emergency Plan for AIDS Relief (PEPFAR). Starting in 2004, PEPFAR supported community outreach programs targeting high-risk populations (people who inject drugs, men who have sex with men, and sex workers). To provide early evidence on program impact, in 2007-2008 we conducted a nationwide evaluation of PEPFAR-supported outreach programs in Vietnam. The evaluation focused on assessing program effect on HIV knowledge, high-risk behaviors, and HIV testing among high-risk populations-results relevant to Vietnam's push to meet global HIV goals. METHODS: We used a mixed-methods cross-sectional evaluation design. Data collection encompassed a quantitative survey of 2199 individuals, supplemented by 125 in-depth interviews. Participants were members of high-risk populations who reported recent contact with an outreach worker (intervention group) or no recent contact (comparison group). We assessed differences in HIV knowledge, risky behaviors, and HIV testing between groups, and between high-risk populations. RESULTS: Intervention participants knew significantly more about transmission, prevention, and treatment than comparison participants. We found low levels of injection drug-use-related risk behaviors and little evidence of program impact on such behaviors. In contrast, a significantly smaller proportion of intervention than comparison participants reported risky sexual behaviors generally and within each high-risk population. Intervention participants were also more likely to have undergone HIV testing (76.1% vs. 47.0%, p < 0.0001) and to have received pre-test (78.0% vs. 33.7%, p < 0.0001) and post-test counseling (80.9% vs. 60.5%, p < 0.0001). Interviews supported evidence of high impact of outreach among all high-risk populations. CONCLUSIONS: Outreach programs appear to have reduced risky sexual behaviors and increased use of HIV testing services among high-risk populations in Vietnam. These programs can play a key role in reducing gaps in the HIV care cascade, achieving the global 90-90-90 goals, and creating an AIDS-free generation.

Do scheduled caste and scheduled tribe women legislators mean lower gender-caste gaps in primary schooling in India?

Despite India's substantial investments in primary schooling, gaps in schooling persist across gender and caste-with scheduled caste and scheduled tribe (SC/ST) girls being particularly disadvantaged. The representation of SC/ST women in state legislatures may help to mitigate this disadvantage. Specifically, because of her intersecting gender and caste/tribe identities, a SC/ST woman legislator might maintain a strong sense of solidarity especially with SC/ST girls and women, and support legislative policies benefitting SC/ST girls. Consequently, for this reason, we expect that living in a district where SC/ST women represent in state legislatures in a higher proportion may increase SC/ST girls' primary school completion, progression and performance. We tested this hypothesis using district-level data between 2000 and 2004 from the Indian Election Commission, the 2004/5 India Human Development Survey, and the Indian Census of 2001. As expected, the representation of SC/ST women in state legislatures was positively associated with SC/ST girls' grade completion and age-appropriate grade progression but was apparent not SC/ST girls' primary-school performance. SC/ST women's representation in state legislatures may reduce gender-caste gaps in primary-school attainment in India.

The economic consequences of selected maternal and early childhood nutrition interventions in low- and middle-income countries: a review of the literature, 2000-2013.

BACKGROUND: Globally, 25% of children aged 0 to 4 years and more than 10% of women aged 15 to 49 years suffer from malnutrition. A range of interventions, promising for improving maternal and child nutrition, may also improve physical and intellectual capacity, and, thereby, future productivity and earnings. METHODS: We conducted a systematic literature review and summarized economic impacts of 23 reproductive, maternal, newborn and child health (RMNCH) interventions, published in 29 empirical studies between 2000 and 2013, using data from 13 low- and middle-income countries. RESULTS: We find that, in low- and middle-income countries, RMNCH interventions were rarely evaluated using rigorous evaluation methods for economic consequences. Nonetheless, based on limited studies, maternal and childhood participation in nutrition interventions was shown to increase individuals' income as adults by up to 46%, depending on the intervention, demography and country. This effect is sizeable considering that poverty reduction interventions, including microfinance and conditional cash transfer programs, have helped increase income by up to 18%, depending on the context. We also found, compared to females, males appeared to have higher economic returns from childhood participation in RMNCH interventions. CONCLUSIONS: Countries with pervasive malnutrition should prioritize investments in RMNCH interventions for their public health benefits. The existing literature is currently too limited, and restricted to a few selected countries, to warrant any major reforms in RMNCH policies based on expected future income impacts. Longitudinal and intergenerational databases remain needed for countries to be better positioned to evaluate maternal and early childhood nutrition intervention programs for future economic consequences.