Future directions for HIV service delivery research: Research gaps identified through WHO guideline development.

Nathan Ford and co-authors discuss the systematic identification of research gaps in improving HIV service delivery.

'They care rudely!': resourcing and relational health system factors that influence retention in care for people living with HIV in Zambia.

INTRODUCTION: Despite access to free antiretroviral therapy (ART), many HIV-positive Zambians disengage from HIV care. We sought to understand how Zambian health system 'hardware' (tangible components) and 'software' (work practices and behaviour) influenced decisions to disengage from care among 'lost-to-follow-up' patients traced by a larger study on their current health status. METHODS: We purposively selected 12 facilities, from 4 provinces. Indepth interviews were conducted with 69 patients across four categories: engaged in HIV care, disengaged from care, transferred to another facility and next of kin if deceased. We also conducted 24 focus group discussions with 158 lay and professional healthcare workers (HCWs). These data were triangulated against two consecutive days of observation conducted in each facility. We conducted iterative multilevel analysis using inductive and deductive reasoning. RESULTS: Health system 'hardware' factors influencing patients' disengagement included inadequate infrastructure to protect privacy; distance to health facilities which costs patients time and money; and chronic understaffing which increased wait times. Health system 'software' factors related to HCWs' work practices and clinical decisions, including delayed opening times, file mismanagement, drug rationing and inflexibility in visit schedules, increased wait times, number of clinic visits, and frustrated access to care. While patients considered HCWs as 'mentors' and trusted sources of information, many also described them as rude, tardy, careless with details and confidentiality, and favouring relatives. Nonetheless, unlike previously reported, many patients preferred ART over alternative treatment (eg, traditional medicine) for its perceived efficacy, cost-free availability and accompanying clinical monitoring. CONCLUSION: Findings demonstrate the dynamic effect of health system 'hardware' and 'software' factors on decisions to disengage. Our findings suggest a need for improved: physical resourcing and structuring of HIV services, preservice and inservice HCWs and management training and mentorship programmes to encourage HCWs to provide 'patient-centered' care and exercise 'flexibility' to meet patients' varying needs and circumstances.

Implementation science for integration of HIV and non-communicable disease services in sub-Saharan Africa: a systematic review.

OBJECTIVE: As the burden of chronic non-communicable diseases (NCDs) rises across sub-Saharan Africa (SSA), global donors and governments are exploring strategies to integrate HIV and NCD care. Implementation science is an emerging research paradigm that can help such programs achieve health impact at scale. We define implementation science as a systematic, scientific approach to ask and answer questions about how to deliver what works in populations who need it with greater speed, appropriate fidelity, efficiency, and relevant coverage. We identified achievements and gaps in the application of implementation science to HIV/NCD integration, developed an HIV/NCD implementation science research agenda, and detailed opportunities for capacity building and training. DESIGN: We conducted a systematic review of the application of implementation science methods to integrated HIV/NCD programs in SSA. METHODS: We searched PubMed, CINAHL, PsycINFO, and EMBASE for evaluations of integrated programs in SSA reporting at least one implementation outcome. RESULTS: We identified 31 eligible studies. We found that most studies used only qualitative, economic, or impact evaluation methods. Only one study used a theoretical framework for implementation science. Acceptability, feasibility, and penetration were the most frequently reported implementation outcomes. Adoption, appropriateness, cost, and fidelity were rare; sustainability was not evaluated. CONCLUSIONS: Implementation science has a promising role in supporting HIV/NCD integration, although its impact will be limited unless theoretical frameworks, rigorous study designs, and reliable measures are employed. To help support use of implementation science, we need to build sustainable implementation science capacity. Doing so in SSA and supporting implementation science investigators can help expedite HIV/NCD integration.

Influence of Substance Use Disorders on 2-Year HIV Care Retention in the United States.

Substance use disorders (SUDs) are thought to predict care discontinuity, though magnitude and substance-specific variance of effects are unclear. This report of analytic work undertaken with a multi-regional American cohort of 9153 care enrollees addresses these gaps. Care retention was computed from 24-month post-linkage clinic visit documentation, with SUD cases identified from patient-report screening instruments. Two generalized estimating equations tested binary and hierarchial SUD predictors of retention, and potential effect modification by patient age-group, sex, and care site. Findings demonstrate: (1) detrimental SUD effect, equivalent to a nine percentage-point decrease in retention, with independent effects of age-group and care site; (2) substance-specific effect of marijuana UD associated with lower retention; and (3) age-modification of each effect on care discontinuity, with SUDs serving as a risk factor among 18-29 year-olds and protective factor among 60+ year-olds. Collective findings document patient attributes as influences that place particular subgroups at-risk to discontinue care.

Prevalence and Factors Associated with Hazardous Alcohol Use Among Persons Living with HIV Across the US in the Current Era of Antiretroviral Treatment.

Hazardous alcohol use is associated with detrimental health outcomes among persons living with HIV (PLWH). We examined the prevalence and factors associated with hazardous alcohol use in the current era using several hazardous drinking definitions and binge drinking defined as ≥5 drinks for men versus ≥4 for women. We included 8567 PLWH from 7 U.S. sites from 2013 to 2015. Current hazardous alcohol use was reported by 27% and 34% reported binge drinking. In adjusted analyses, current and past cocaine/crack (odd ratio [OR] 4.1:3.3-5.1, p < 0.001 and OR 1.3:1.1-1.5, p < 0.001 respectively), marijuana (OR 2.5:2.2-2.9, p < 0.001 and OR 1.4:1.2-1.6, p < 0.001), and cigarette use (OR 1.4:1.2-1.6, p < 0.001 and OR 1.3:1.2-1.5, p < 0.001) were associated with increased hazardous alcohol use. The prevalence of hazardous alcohol use remains high in the current era, particularly among younger men. Routine screening and targeted interventions for hazardous alcohol use, potentially bundled with interventions for other drugs, remain a key aspect of HIV care.

Implementation and operational research: evaluating outcomes of patients lost to follow-up in a large comprehensive care treatment program in western Kenya.

BACKGROUND: Academic Model Providing Access To Healthcare (AMPATH) program provides comprehensive HIV care and treatment services. Approximately, 30% of patients have become lost to follow-up (LTFU). We sought to actively trace and identify outcomes for a sample of these patients. METHODS: LTFU was defined as missing a scheduled visit by ≥3 months. A randomly selected sample of 17% of patients identified as LTFU between January 2009 and June 2011 was generated, with sample stratification on age, antiretroviral therapy (ART) status at last visit, and facility. Chart reviews were conducted followed by active tracing. Tracing was completed by trained HIV-positive outreach workers July 2011 to February 2012. Outcomes were compared between adults and children and by ART status. RESULTS: Of 14,811 LTFU patients, 2540 were randomly selected for tracing (2179 adults, 1071 on ART). The chart reviews indicated that 326 (12.8%) patients were not actually LTFU. Outcomes for 71% of sampled patients were determined including 85% of those physically traced. Of those with known outcomes, 21% had died, whereas 29% had disengaged from care for various reasons. The remaining patients had moved away (n = 458, 25%) or were still receiving HIV care (n = 443 total, 25%). CONCLUSIONS: Our findings demonstrate the feasibility of a large-scale sampling-based approach. A significant proportion of patients were found not to be LTFU, and further, high numbers of patients who were LTFU could not be located. Over a quarter of patients disengaged from care for various reasons including access challenges and familial influences.

Diminishing availability of publicly funded slots for antiretroviral initiation among HIV-infected ART-eligible patients in Uganda.

BACKGROUND: The impact of flat-line funding in the global scale up of antiretroviral therapy (ART) for HIV-infected patients in Africa has not yet been well described. METHODS: We evaluated ART-eligible patients and patients starting ART at a prototypical scale up ART clinic in Mbarara, Uganda between April 1, 2009 and May 14, 2010 where four stakeholders sponsor treatment - two PEPFAR implementing organizations, the Ugandan Ministry of Health - Global Fund (MOH-GF) and a private foundation named the Family Treatment Fund (FTF). We assessed temporal trends in the number of eligible patients, the number starting ART and tabulated the distribution of the stakeholders supporting ART initiation by month and quartile of time during this interval. We used survival analyses to assess changes in the rate of ART initiation over calendar time. FINDINGS: A total of 1309 patients who were eligible for ART made visits over the 14 month period of the study and of these 819 started ART. The median number of ART eligible patients each month was 88 (IQR: 74 to 115). By quartile of calendar time, PEPFAR and MOH sponsored 290, 192, 180, and 49 ART initiations whereas the FTF started 1, 2, 1 and 104 patients respectively. By May of 2010 (the last calendar month of observation) FTF sponsored 88% of all ART initiations. Becoming eligible for ART in the 3(rd) (HR = 0.58, 95% 0.45-0.74) and 4(th) quartiles (HR = 0.49, 95% CI: 0.36-0.65) was associated with delay in ART initiation compared to the first quartile in multivariable analyses. INTERPRETATION: During a period of flat line funding from multinational donors for ART programs, reductions in the number of ART initiations by public programs (i.e., PEPFAR and MOH-GF) and delays in ART initiation became apparent at the a large prototypical scale-up ART clinic in Uganda.