Which Features of Telehealth in HIV Care Are Most Important? A Mixed-Methods Study With HIV Care Providers and People Living With HIV in South Carolina.

ABSTRACT: Telehealth was rapidly implemented in HIV care during COVID-19 yet remains understudied. To assess the importance of telehealth features, we conducted a mixed-methods study with HIV care providers and people living with HIV. Qualitative interviews and ranking exercises revealed heterogeneity in preference-relevant features of telehealth in HIV care.

Stigmatizing clinical setting erodes physician-patient interaction quality for sexual minority men through perceived HIV stigma and HIV infection concerns in Zambia.

This study investigated whether perceived HIV stigma and HIV infection concerns among healthcare providers (HCPs) mediate the association between stigmatizing clinical setting and their interaction quality with sexual minority men (SMM) patients in Zambia. In 2021, a cross-sectional survey was conducted with 91 HCPs offering HIV-related services to SMM in Zambia. Path analysis was conducted to examine the potential mediation effect of "perceived HIV stigma" and "HIV infection concern" among HCPs in the association between "stigmatizing clinical setting" and their "interaction quality with SMM". Mediators i.e., "perceived HIV stigma" and "HIV infection concern" among HCPs, were associated positively with the stigmatizing clinical setting (ß = 0.329, p < .01, ß = 0.917, p < 0.01), and negatively with physician-patient interaction quality (ß = -0.167, p = 0.051; ß = -0.126, p < 0.05). Stigmatizing clinical setting had a significant and negative indirect effect on HCPs interaction quality with SMM through increased perceived HIV stigma (z = -1.966, p < 0.05) and increased HIV infection concern (z = -1.958, p = 0.050). To improve physician-patient interaction quality, stigma reduction interventions among HCPs, who serve SMM in Zambia, should target development of development of inclusive policies and the cultivation of cultural norms that are supportive and respectful to SMM, and protection of HCPs from enacted stigma due to offering care to SMM.

Disparities in Telehealth Use in HIV Care During the COVID-19 Pandemic: Study Findings from South Carolina.

Background: Telehealth was adopted to maintain HIV care continuity during the COVID-19 pandemic; however, its use was unequally distributed. This study examined variation in HIV care visit patterns and whether telehealth use was associated with viral suppression. Methods: Electronic health record (EHR) data from a large HIV clinic in South Carolina was analyzed using multivariable logistic regression to characterize variation in telehealth use, having a viral load (VL) test, and viral suppression in 2022. Results: EHR data from 2,375 people living with HIV (PWH) between March 2021 and March 2023 showed telehealth use among 4.8% of PWH. PWH who are 50+ years and non-Hispanic Black had lower odds of telehealth use (odds ratio [OR] 0.59, 95% confidence interval [CI 0.40-0.86]; OR 0.58, 95% CI [0.37-0.92] respectively). Telehealth use was not associated with viral suppression and VL testing. Conclusion: Telehealth disparities in HIV care affected older and non-Hispanic Black PWH, requiring tailored strategies to promote telehealth among them.

Impact of enacted stigma on mental health, substance use, and HIV-related behaviors among sexual minority men in Zambia.

Sexual minority men (SMM) in Zambia face significant challenges including stigma, discrimination, and mental health issues, which further impact their HIV-related risk behaviors. This study aimed to investigate the associations between enacted stigma, substance abuse, HIV-related behaviors, and mental health (i.e., depression, anxiety, and post-traumatic stress disorder [PTSD] symptoms) among SMM in Zambia. SMM aged 18-35 years who reported having multiple and/or concurrent sexual partners or low and/or inconsistent condom use in the past three months were recruited from four districts in Zambia between February and November 2021. Participants completed an anonymous interviewer-administered survey. Key variables of interest were compared between participants with higher vs. lower levels of enacted stigma. Independent samples t-tests were used for continuous variables, and chi-squared tests were used for categorical variables. A total of 197 eligible SMM participated in the study (mean age = 24.41 years). Participants with a higher level of enacted stigma showed a higher level of anxiety symptoms (χ2 = 12.91, p ≤ .001), PTSD symptoms (χ2 = 7.13, p < .01), tobacco use (χ2 = 10.47, p < .01), cannabis use (χ2 = 5.90, p < .05), and a higher number of sexual partners (t = 1.99, p < .05) in the past three months. Stigma reduction interventions may help mitigate substance abuse, HIV-related behaviors, and adverse mental health outcomes among SMM in Zambia. Health care providers, especially psychiatric-mental health nurses, can incorporate strategies for recognizing and addressing stigma into their practice through training and integrate multiple resources to create an inclusive and non-judgmental environment for SMM to improve their well-being.

American Indian/Alaska Native men are less likely to receive prostate-specific antigen testing and digital rectal exams from primary care providers than White men: a secondary analysis of the National Ambulatory Medical Care Survey from 2012-2018.

PURPOSE: (1) Identify the proportion of primary care visits in which American Indian/Alaska Native (AI/AN) men receive a prostate-specific antigen test (PSAT)and/or a digital rectal exam (DRE), (2) describe characteristics of primary care visits in which AI/AN receive PSA and/or DRE, and (3) identify whether AI/AN receive PSA and/or DRE less often than non-Hispanic White (nHW) men. METHODS: This was a secondary analysis of the National Ambulatory Medical Care Survey (NAMCS) during 2013-2016 and 2018 and the NAMCS Community Health Center (CHC) datasets from 2012-2015. Weighted bivariate and multivariable tests analyzed the data to account for the complex survey design. RESULTS: For AI/AN men, 1.67 per 100 visits (95% CI = 0-4.24) included a PSATs (or PSAT) and 0 visits included a DRE between 2013-2016 and 2018. The rate of PSA for non-AI/AN men was 9.35 per 100 visits (95% CI = 7.78-10.91) and 2.52 per 100 visits (95% CI = 1.61-3.42) for DRE. AI/AN men were significantly less likely to receive a PSA than nHW men (aOR = 0.09, 95% CI = 0.01-0.83). In CHCs, AI/AN men experienced 4.26 PSAT per 100 visits (95% CI = 0.96-7.57) compared to 5.00 PSAT per 100 visits (95% CI = 4.40-5.68) for non-AI/AN men. DRE rates for AI/AN men was 0.63 per 100 visits (95% CI = 0-1.61) compared to 1.05 per 100 (95% CI = 0.74-1.37) for non-AI/AN men. There was not a statistically significant disparity in the CHC data regarding PSA (OR = 0.91, 95% CI = 0.42-1.98) or DRE (OR = 0.75, 95% CI = 0.15-3.74), compared to nHW men. CONCLUSION: Efforts are needed to better understand why providers may not use PSA and DRE with AI/AN men compared to nHW men.

Ageing with HIV in the United States: Changing trends in inpatient hospital stays and comorbidities, 2003-2015.

INTRODUCTION: As people with HIV (PWH) age, they experience prolonged exposure to HIV and antiretroviral therapy, increased risks of developing age-related HIV-associated non-AIDS (HANA) comorbidities and higher rates of hospitalization. Few studies have explored the ageing of PWH and its impact on hospital stays in the US. This study examined trends, characteristics and comorbidities associated with hospital stays with HIV (HSWH) as compared with hospital stays without HIV (HSWOH). METHODS: Thirteen years of pooled National Inpatient Sample (NIS) data from 2003 through 2015 were analysed to describe yearly trends. Trends were evaluated for eight major HANA conditions (cardiovascular disease, cancer, diabetes, liver disease, bone loss, kidney disease, pulmonary disease and neurological disease) across four age groups (18-34, 35-49, 50-64, 65+ years). RESULTS: Although overall rates of hospitalization reduced across all age groups, the proportion of HIV-related hospitalization increased among older Americans. The average number of chronic conditions was higher for HSWH among all age groups and disproportionately increased for older PWH. Although age-adjusted rates of cardiovascular disease, cancer, bone loss and pulmonary disease were lower for HSWH relative to HSWOH, rates increased disproportionately over the study period. The prevalence of all major HANA conditions except cancer and diabetes increased among the elderly (65+), and the prevalence of cardiovascular disease, cancer, bone loss, kidney disease and pulmonary disease also increased among patients aged 50-64 years. CONCLUSIONS: Higher rates of hospitalizations and HANA comorbidities were observed among older HIV patients. The ageing of PWH suggests increased future hospital resource utilization for HSWH. Appropriate training of healthcare providers is essential to managing increased comorbidity burdens of older PWH during hospital stays in the US.

Physician-Patient Interaction Quality Mediates the Association Between HIV-Related Stigma and HIV-Prevention Behaviors Among Sexual Minority Men in Zambia.

HIV-related stigma is a major challenge to HIV prevention for sexual minority men (SMM) in Zambia, but little is known about the underlying mechanisms. This study aimed to investigate whether physician-patient interaction quality mediates the relationship between HIV-related stigma and HIV-prevention behaviors among SMM. Data were collected using a cross-sectional survey from 194 SMM (aged: mean = 24.08, SD = 4.27) across four districts in Zambia between February and November 2021. Participants were asked about their demographic characteristics, HIV-related stigma, SMM-related stigma, physician-patient interaction quality, HIV-testing intention, and use of pre-exposure prophylaxis (PrEP). Path analysis was used to test the mediation effect of physician-patient interaction quality in the associations of HIV-related stigma/SMM-related stigma with HIV-testing intention and current PrEP use. Higher self-reported physician-patient interaction quality was negatively associated with HIV-related stigma (ß = - 0.444, z = - 2.223, p < 0.05), and positively associated with HIV-testing intention (ß = 0.039, z = 5.121, p < 0.001) and current PrEP use (ß = 0.008, z = 2.723, p < 0.01). HIV-related stigma among SMM had a significant and negative indirect effect on HIV-testing intention (ß = - 0.017, z = - 2.006, p < 0.05), and current PrEP use (ß = - 0.004, z = - 2.009, p < 0.05) through physician-patient interaction quality. Contrary to our expectations, SMM-related stigma did not have a significant and negative indirect effect on HIV prevention behaviors through physician-patient interaction quality. Health interventions need to improve physician-patient interaction quality by offering healthcare provider training, targeting HIV-related stigma in healthcare settings, and devising inclusive healthcare policies to promote HIV prevention efforts.

Divergent preferences for enhanced HIV testing options among high-risk populations in northern Tanzania: a short report.

To achieve the UNAIDS target of diagnosing 95% of all persons living with HIV, enhanced HIV testing services with greater attractional value need to be developed and implemented. We conducted a discrete choice experiment (DCE) to quantify preferences for enhanced HIV testing features across two high-risk populations in the Kilimanjaro Region in northern Tanzania. We designed and fielded a survey with 12 choice tasks to systematically recruited female barworkers and male mountain porters. Key enhanced features included: testing availability on every day of the week, an oral test, integration of a general health check or an examination for sexually transmitted infections (STI) with HIV testing, and provider-assisted confidential partner notification in the event of a positive HIV test result. Across 300 barworkers and 440 porters surveyed, mixed logit analyses of 17,760 choices indicated strong preferences for everyday testing availability, health checks, and STI examinations. Most participants were averse to oral testing and confidential partner notification by providers. Substantial preference heterogeneity was observed within each risk group. Enhancing HIV testing services to include options for everyday testing, general health checks, and STI examinations may increase the appeal of HIV testing offers to high-risk populations.Trial registration: ClinicalTrials.gov identifier: NCT02714140.

Patient attitudes and beliefs associated with self-referral to physical therapy for musculoskeletal complaints: a qualitative study.

BACKGROUND: Non-pharmacologic treatments such as physical therapy (PT) are advocated for musculoskeletal pain. Early access to PT through self-referral has been shown to decrease costs and improve outcomes. Although self-referral is permitted in most U.S. states and supported by some health insurance plans, patients' utilization of self-referral remains low. OBJECTIVE: To identify factors, beyond legislative policies and health insurance, associated with patients' decisions to access physical therapy through self-referral or provider-referral. METHODS: We recruited 26 females and 6 males whose employer-sponsored insurance benefits included financial incentives for self-referral to physical therapy. Between August 2017 and March 2018, participants completed semi-structured interviews about their beliefs about physical therapy and reasons for choosing self-referral (15 participants) or provider referral (17 participants) for accessing physical therapy. Grounded theory approach was employed to identify themes in the data. RESULTS: Patients selecting self-referral reported major thematic differences compared to the provider-referral patients including knowledge of the direct access program, attitudes and beliefs about physical therapy and pharmacologic treatment, and prior experiences with physical therapy. Self-referral patients were aware that their plan benefits included reduced cost for self-referral and felt confident in selecting that pathway. They also had negative beliefs about the effectiveness of pharmacological treatments and surgery, and previously had positive direct or indirect experiences with physical therapy. CONCLUSION: Knowledge of the ability to self-refer, attitudes and beliefs about treatment, and prior experience with physical therapy were associated with self-referral to physical therapy. Interventions aimed at improving knowledge and changing attitudes toward self-referral to physical therapy to increase utilization appear warranted.

Feasibility, Acceptability, and Potential Cost-Effectiveness of a Novel Mobile Phone Intervention to Promote Human Immunodeficiency Virus Testing Within Social Networks in Tanzania.

ABSTRACT: Among 145 individuals surveyed in Tanzania, 42% indicated willingness to test for human immunodeficiency virus in response to a confidential, phone-based text message. On average, participants were likely to provide contact information for 1.5 members of their social networks, suggesting high feasibility and moderate acceptability of a novel mHealth human immunodeficiency virus testing intervention.

The association between urban greenspace and psychological health among young adults in Addis Ababa, Ethiopia.

INTRODUCTION: Psychological disorders are emerging as health priorities in Sub-Saharan Africa, specifically Ethiopia. Urban greenspace - parks, trees, and other vegetation integrated into urban form - may facilitate population psychological health, but is largely understudied outside high-income countries. We explore greenspace in relation to psychological health among young adults in Addis Ababa, Ethiopia. METHOD: Greenspace exposure was calculated using the normalized difference vegetation index (NDVI) derived from publicly available satellite imagery (2018-2019). We used tests of spatial clustering to characterize greenspace distribution. Derived NDVI values were linked to Positive Outcomes for Orphans study participants to explore cross-sectional associations between greenspace exposure and psychological health (measured 2019-2021). Two continuous scores of psychological health were examined: total difficulties from the Strengths and Difficulties Questionnaire and depressive symptoms from the 8-item Patient Health Questionnaire. Multilevel generalized linear regression, nested by administrative units, was used to estimate the association between greenspace and psychological health. We also explored effect modification by gender and having income. RESULTS: We found greenspace is spatially clustered in Addis Ababa, with high greenspace density in the northeast region and low greenspace density in the center of the city. Our findings suggest residing in greener areas is associated with fewer emotional and behavioral difficulties (ß = -1.89; 95% CI: -3.50, -0.29), but not significantly associated with depressive symptomology (ß = -0.61; 95% CI: -2.33, 1.11). We observed stronger associations between greenspace and total difficulties among those reporting any income and among males, and for the association between greenspace and depression symptomology among males. CONCLUSION: We offer initial exploration into the role of greenspace in psychological well-being in Addis Ababa, with potential implications for urban communities across Sub-Saharan Africa. Further research should continue to explore how the built and natural environment could be leveraged in similar settings to promote population psychological health.

Job attributes valued by physicians, PAs, and NPs: A cross-sectional survey.

OBJECTIVE: This study evaluated the relative importance of job-, community-, and individual-related factors that contribute to job choice among physicians, physician assistants (PAs), and NPs, to inform policy options to recruit clinicians to rural areas. METHODS: A cross-sectional online survey of PA preceptors from three institutions in two states. Participants were asked to rate the importance of 16 job-, community-, and individual-related factors when choosing a job. RESULTS: We received responses from 45 physicians, 74 PAs, and 15 NPs (24.2% response rate), who rated most job-, community-, and individual-related factors as important; ratings were similar across clinicians. PAs rated loan repayment programs and work hours higher than physicians, though the magnitude of the difference was small. CONCLUSIONS: Clinicians similarly rated many factors as important. A better understanding of the tradeoffs clinicians are willing to make between these factors when making a job choice is critical to increase the attractiveness of rural positions.

Increasing the Uptake of HIV Testing among Men in Tanzania: A Novel Intervention for Bar Patrons.

We investigated a novel community-based HIV testing and counseling (HTC) strategy by recruiting men from bars in northern Tanzania in order to identify new HIV infections. All bars in the town of Boma Ng'ombe were identified and male patrons were systematically invited to participate in a health study. HIV testing was offered to all enrolled participants. Outputs included HIV test yield, cost per diagnosis, and comparison of our observed test yield to that among male patients contemporaneously tested at five local facility-based HTC. We enrolled 366 participants and identified 17 new infections - providing a test yield of 5.3% (95% Confidence interval [CI] 3.3-8.4). The test yield among men contemporaneously tested at five local HTC centers was 2.1% (95% CI 1.6-2.8). The cost-per-diagnosis was $634. Our results suggest that recruiting male bar patrons for HIV testing is efficient for identifying new HIV infections. The scalability of this intervention warrants further evaluation.

RESUMEN: Investigamos una novedosa estrategia comunitaria de asesoramiento y pruebas de VIH (HTC) reclutando hombres de los bares del norte de Tanzania para identificar nuevas infecciones de VIH. Se identificaron todos los bares de la ciudad de Boma Ng'ombe y se invitó sistemáticamente a los clientes varones a participar en un estudio de salud. Se ofrecieron pruebas de VIH a todos los participantes inscritos. Los resultados incluyeron los resultados de las pruebas de VIH, el costo por diagnóstico y la comparación de nuestros resultados observados con los de los pacientes varones que simultáneamente se sometieron a pruebas en cinco centros locales de HTC. Se inscribieron 366 participantes y se identificaron 17 nuevas infecciones, proporcionando un resultado en las pruebas del 5.3% (intervalo de confianza [IC] del 95%: 3.3-8.4). Los resultados de las pruebas realizadas simultáneamente en cinco centros locales de HTC fue del 2.1% (IC del 95%: 1.6-2.8). El costo por diagnóstico fue de $634. Nuestros resultados sugieren que el reclutamiento de clientes masculinos para las pruebas de VIH fue eficiente para identificar nuevas infecciones de VIH. La escalabilidad de esta intervención merece una evaluación adicional.

Heterogeneous Patient Preferences for Modern Antiretroviral Therapy: Results of a Discrete Choice Experiment.

OBJECTIVE: Limited data describe patient preferences for the growing number of antiretroviral therapies (ARTs). We quantified preferences for key characteristics of modern ART deemed relevant to shared decision making. METHODS: A discrete choice experiment survey elicited preferences for ART characteristics, including dosing (frequency and number of pills), administration characteristics (pill size and meal requirement), most bothersome side effect (from diarrhea, sleep disturbance, headaches, dizziness/difficulty thinking, depression, or jaundice), and most bothersome long-term effect (from increased risk of heart attacks, bone fractures, renal dysfunction, hypercholesterolemia, or hyperglycemia). Between March and August 2017, the discrete choice experiment was fielded to 403 treatment-experienced persons living with human immunodeficiency virus (HIV), enrolled from 2 infectious diseases clinics in the southern United States and a national online panel. Participants completed 16 choice tasks, each comparing 3 treatment options. Preferences were analyzed using mixed and latent class logit models. RESULTS: Most participants were male (68%) and older (interquartile range: 42-58 years), and had substantial treatment experience (interquartile range: 7-21 years). In mixed logit analyses, all attributes were associated with preferences. Side and long-term effects were most important, with evidence of substantial preference heterogeneity. Latent class analysis identified 5 preference classes. For classes 1 (40%), 2 (24%), and 3 (21%), side effects were most important, followed by long-term effects. For class 4 (10%), dosing was most important. Class 5 (4%) was largely indifferent to ART characteristics. CONCLUSION: Overall, treatment-experienced persons living with HIV valued minimizing side effects and long-term toxicities over dosing and administration characteristics. Preferences varied widely, highlighting the need to elicit individual patient preferences in models of shared antiretroviral decision making.

Health Preference Research in Europe: A Review of Its Use in Marketing Authorization, Reimbursement, and Pricing Decisions-Report of the ISPOR Stated Preference Research Special Interest Group.

OBJECTIVE: This study examines European decision makers' consideration and use of quantitative preference data. METHODS: The study reviewed quantitative preference data usage in 31 European countries to support marketing authorization, reimbursement, or pricing decisions. Use was defined as: agency guidance on preference data use, sponsor submission of preference data, or decision-maker collection of preference data. The data could be collected from any stakeholder using any method that generated quantitative estimates of preferences. Data were collected through: (1) documentary evidence identified through a literature and regulatory websites review, and via key opinion leader outreach; and (2) a survey of staff working for agencies that support or make healthcare technology decisions. RESULTS: Preference data utilization was identified in 22 countries and at a European level. The most prevalent use (19 countries) was citizen preferences, collected using time-trade off or standard gamble methods to inform health state utility estimation. Preference data was also used to: (1) value other impact on patients, (2) incorporate non-health factors into reimbursement decisions, and (3) estimate opportunity cost. Pilot projects were identified (6 countries and at a European level), with a focus on multi-criteria decision analysis methods and choice-based methods to elicit patient preferences. CONCLUSION: While quantitative preference data support reimbursement and pricing decisions in most European countries, there was no utilization evidence in European-level marketing authorization decisions. While there are commonalities, a diversity of usage was identified between jurisdictions. Pilots suggest the potential for greater use of preference data, and for alignment between decision makers.

Parental concerns and uptake of childhood vaccines in rural Tanzania - a mixed methods study.

BACKGROUND: Vaccine hesitancy has been recognized as an important barrier to timely vaccinations around the world, including in sub-Saharan Africa. In Tanzania, 1 in 4 children is not fully vaccinated. The objective of this mixed methods study was to describe and contextualize parental concerns towards vaccines in Tanzania. METHODS: Between 2016 and 2017, we conducted a cross-sectional survey (n = 134) and four focus group discussions (FGDs, n = 38) with mothers of children under 2 years of age residing in Mtwara region in Southern Tanzania. The survey and FGDs assessed vaccination knowledge and concerns and barriers to timely vaccinations. Vaccination information was obtained from government-issued vaccination cards. RESULTS: In the cross-sectional survey, 72% of mothers reported missed or delayed receipt of vaccines for their child. Although vaccine coverage was high, timeliness of vaccinations was lower and varied by vaccine. Rural mothers reported more vaccine-related concerns compared to urban mothers; literacy and access to information were identified as key drivers of the difference. Mothers participating in FGDs indicated high perceived risk of vaccine-preventable illnesses, but expressed concerns related to poor geographic accessibility, unreliability of services, and missed opportunities for vaccinations resulting from provider efforts to minimize vaccine wastage. CONCLUSIONS: Findings from our cross-sectional survey indicate the presence of vaccination delays and maternal concerns related to childhood vaccines in Tanzania. In FGDs, mothers raised issues related to convenience more often than issues related to vaccine confidence or complacency. Further research is necessary to understand how these issues may contribute to the emergence and persistence of vaccine hesitancy and to identify effective mitigation strategies.

Potentially traumatic experiences and sexual health among orphaned and separated adolescents in five low- and middle-income countries.

Orphans and separated children (OSC) are a vulnerable population whose numbers are increasing, particularly in sub-Saharan Africa and Asia. Over 153 million children worldwide have lost one or both parents, including 17 million orphaned by AIDS, and millions more have been separated from their parents. As younger orphans enter adolescence, their sexual health and HIV-related risk behaviors become key considerations for their overall health. Importantly, their high prevalence of exposure to potentially traumatic events (PTEs) may put OSC at additional risk for adverse sexual health outcomes. The Positive Outcomes for Orphans study followed OSC randomly sampled from institution-based care and from family-based care, as well as a convenience sample of non-OSC, at six sites in five low-and middle-income countries. This analysis focused on the 90-month follow-up, during which adolescents 16 and older were assessed for sexual health, including age at sexual debut, past-year sex, past-year condom use, and perceptions of condom use. We specifically examined the relationship between PTEs and sexual health outcomes. Of the 1258 OSC and 138 non-OSC assessed, 11% reported ever having sex. Approximately 6% of participants reported recent sex and 5% reported having recent unprotected sex. However, 70% of those who had recent sex reported that they did not use a condom every time, and perceptions of condom use tended to be unfavorable for protection against sexual risk behavior. Nearly all (90%) of participants reported experiencing at least one lifetime PTE. For those who experienced "any" PTE, we found increased prevalence of recent sex (PR = 1.39 [0.47, 4.07]) and of recent unprotected sex (PR = 3.47 [0.60, 19.91]). This study highlights the need for caregivers, program managers, and policymakers to promote condom use for sexually active OSC and identify interventions for trauma support services. Orphans living in family-based care may also be particularly vulnerable to early sexual debut and unprotected sexual activity.

Test site predicts HIV care linkage and antiretroviral therapy initiation: a prospective 3.5 year cohort study of HIV-positive testers in northern Tanzania.

BACKGROUND: Linkage to HIV care is crucial to the success of antiretroviral therapy (ART) programs worldwide, loss to follow up at all stages of the care continuum is frequent, and long-term prospective studies of care linkage are currently lacking. METHODS: Consecutive clients who tested HIV-positive were enrolled from four HIV testing centers (1 health facility and 3 community-based centers) in the Kilimanjaro region of Tanzania as part of the larger Coping with HIV/AIDS in Tanzania (CHAT) prospective observational study. Biannual interviews were conducted over 3.5 years, assessing care linkage, retention, and mental health. Bivariable and multivariate logistic regression analyses were conducted to determine associations with early death (prior to the second follow up interview) and delayed (>6 months post-test) or failed care linkage. RESULTS: A total of 263 participants were enrolled between November, 2008 and August, 2009 and 240 participants not already linked to care were retained in the final dataset. By 6 months after enrollment, 169 (70.4 %) of 240 participants had presented to an HIV care and treatment facility; 41 (17.1 %) delayed more than 6 months, 15 (6.3 %) died, and 15 (6.3 %) were lost to follow up. Twenty-six patients died before their second follow up visit and were analyzed in the early death group (10.8 %). Just 15 (9.6 %) of those linked to care had started ART within 6 months, but 123 (89.1 %) of patients documented to be ART eligible by local guidelines had started ART by the end of 3.5 years. On multivariate analysis, male gender (OR 1.72; 95 % CI 1.08, 2.75), testing due to illness (OR 1.63; 95 % CI 1.01, 2.63), and higher mean depression scale scores (4 % increased risk per increase in depression score; 95 % CI 1 %, 8 %) were associated with early death. Testing at a community versus a hospital-based site (OR 2.89; 95 % CI 1.79, 4.66) was strongly associated with delaying or never entering care. CONCLUSIONS: Nearly 30 % of the cohort did not have timely care linkage, ART initiation was frequently delayed, and testing at a hospital outpatient department versus community-based testing centers was strongly associated with successful care linkage.

Civic engagement among orphans and non-orphans in five low- and middle-income countries.

BACKGROUND: Communities and nations seeking to foster social responsibility in their youth are interested in understanding factors that predict and promote youth involvement in public activities. Orphans and separated children (OSC) are a vulnerable population whose numbers are increasing, particularly in resource-poor settings. Understanding whether and how OSC are engaged in civic activities is important for community and world leaders who need to provide care for OSC and ensure their involvement in sustainable development. METHODS: The Positive Outcomes for Orphans study (POFO) is a multi-country, longitudinal cohort study of OSC randomly sampled from institution-based care and from family-based care, and of non-OSC sampled from the same study regions. Participants represent six sites in five low-and middle-income countries. We examined civic engagement activities and government trust among subjects > =16 years old at 90-month follow-up (approximately 7.5 years after baseline). We calculated prevalences and estimated the association between key demographic variables and prevalence of regular volunteer work using multivariable Poisson regression, with sampling weights to accounting for the complex sampling design. RESULTS: Among the 1,281 POFO participants > =16 who were assessed at 90-month follow-up, 45 % participated in regular community service or volunteer work; two-thirds of those volunteers did so on a strictly voluntary basis. While government trust was fairly high, at approximately 70 % for each level of government, participation in voting was only 15 % among those who were > =18 years old. We did not observe significant associations between demographic characteristics and regular volunteer work, with the exception of large variation by study site. CONCLUSION: As the world's leaders grapple with the many competing demands of global health, economic security, and governmental stability, the participation of today's youth in community and governance is essential for sustainability. This study provides a first step in understanding the degree to which OSC from different care settings across multiple low- and middle-income countries are engaged in their communities.

One size does not fit all: HIV testing preferences differ among high-risk groups in Northern Tanzania.

In order to maximize the effectiveness of "Seek, Test, and Treat" strategies for curbing the HIV epidemic, new approaches are needed to increase the uptake of HIV testing services, particularly among high-risk groups. Low HIV testing rates among such groups suggest that current testing services may not align well with the testing preferences of these populations. Female bar workers and male mountain porters have been identified as two important high-risk groups in the Kilimanjaro Region of Tanzania. We used conventional survey methods and a discrete choice experiment (DCE), a preference elicitation method increasingly applied by economists and policy-makers to inform health policy and services, to analyze trade-offs made by individuals and quantify preferences for HIV testing services. Bivariate descriptive statistics were used to analyze differences in survey responses across groups. Compared to 486 randomly selected community members, 162 female bar workers and 194 male Kilimanjaro porters reported 2-3 times as many lifetime sexual partners (p < 0.001), but similar numbers of lifetime HIV tests (median 1-2 across all groups). For the DCE, participants' stated choices across 12,978 hypothetical HIV testing scenarios (422 female and 299 male participants × 9 choice tasks × 2 alternatives) were analyzed using gender-specific mixed logit models. Direct assessments and the DCE data demonstrated that barworkers were less likely to prefer home testing and were more concerned about disclosure issues compared with their community counterparts. Male porters preferred testing in venues where antiretroviral therapy was readily available. Both high-risk groups were less averse to traveling longer distances to test compared to their community counterparts. These results expose systematic differences in HIV testing preferences across high-risk populations compared to their community peers. Tailoring testing options to the preferences of high-risk populations should be evaluated as a means of improving uptake of testing in these populations.