Electronic Medical Record Data Missingness and Interruption in Antiretroviral Therapy Among Adults and Children Living With HIV in Haiti: Retrospective Longitudinal Study.

Background: Children (aged 0-14 years) living with HIV often experience lower rates of HIV diagnosis, treatment, and viral load suppression. In Haiti, only 63% of children living with HIV know their HIV status (compared to 85% overall), 63% are on treatment (compared to 85% overall), and 48% are virally suppressed (compared to 73% overall). Electronic medical records (EMRs) can improve HIV care and patient outcomes, but these benefits are largely dependent on providers having access to quality and nonmissing data. Objective: We sought to understand the associations between EMR data missingness and interruption in antiretroviral therapy treatment by age group (pediatric vs adult). Methods: We assessed associations between patient intake record data missingness and interruption in treatment (IIT) status at 6 and 12 months post antiretroviral therapy initiation using patient-level data drawn from iSanté, the most widely used EMR in Haiti. Missingness was assessed for tuberculosis diagnosis, World Health Organization HIV stage, and weight using a composite score indicator (ie, the number of indicators of interest missing). Risk ratios were estimated using marginal parameters from multilevel modified Poisson models with robust error variances and random intercepts for the facility to account for clustering. Results: Data were drawn from 50 facilities and comprised 31,457 patient records from people living with HIV, of which 1306 (4.2%) were pediatric cases. Pediatric patients were more likely than adult patients to experience IIT (n=431, 33% vs n=7477, 23.4% at 6 months; P<.001). Additionally, pediatric patient records had higher data missingness, with 581 (44.5%) pediatric records missing at least 1 indicator of interest, compared to 7812 (25.9%) adult records (P<.001). Among pediatric patients, each additional indicator missing was associated with a 1.34 times greater likelihood of experiencing IIT at 6 months (95% CI 1.08-1.66; P=.008) and 1.24 times greater likelihood of experiencing IIT at 12 months (95% CI 1.05-1.46; P=.01). These relationships were not statistically significant for adult patients. Compared to pediatric patients with 0 missing indicators, pediatric patients with 1, 2, or 3 missing indicators were 1.59 (95% CI 1.26-2.01; P<.001), 1.74 (95% CI 1.02-2.97; P=.04), and 2.25 (95% CI 1.43-3.56; P=.001) times more likely to experience IIT at 6 months, respectively. Among adult patients, compared to patients with 0 indicators missing, having all 3 indicators missing was associated with being 1.32 times more likely to experience IIT at 6 months (95% CI 1.03-1.70; P=.03), while there was no association with IIT status for other levels of missingness. Conclusions: These findings suggest that both EMR data quality and quality of care are lower for children living with HIV in Haiti. This underscores the need for further research into the mechanisms by which EMR data quality impacts the quality of care and patient outcomes among this population. Efforts to improve both EMR data quality and quality of care should consider prioritizing pediatric patients.

Does HIV index testing bring patients into treatment at earlier stages of HIV disease? Results from a retrospective study in Ukraine.

BACKGROUND: Over one-third of people living with HIV (PLH) in Ukraine are not on treatment. Index testing services, which link potentially exposed partners (named partners) of known PLH (index patients) with testing and treatment services, are being scaled in Ukraine and could potentially close this gap. METHODS: This retrospective study included patient data from 14,554 adult PLH who initiated antiretroviral treatment (ART) between October 2018 and May 2021 at one of 35 facilities participating in an intervention to strengthen index testing services. Mixed effects modified Poisson models were used to assess differences between named partners and other ART initiators, and an interrupted time series (ITS) analysis was used to assess changes in ART initiation over time. RESULTS: Compared to other ART initiators, named partners were significantly less likely to have a confirmed TB diagnosis (aRR = 0.56, 95% CI = 0.40, 0.77, p < 0.001), a CD4 count less than 200 cells/mm3 (aRR = 0.84, 95% CI = 0.73, 0.97, p = 0.017), or be categorized as WHO HIV stage 4 (aRR = 0.68, 9% CI = 0.55, 0.83, p < 0.001) at the time of ART initiation, and were significantly more likely to initiate ART within seven days of testing for HIV (aRR = 1.36, 95% CI = 1.22, 1.50, p < 0.001). Our ITS analysis showed a modest 2.34% (95% CI = 0.26%, 4.38%; p = 0.028) month-on-month reduction in mean ART initiations comparing the post-intervention period to the pre-intervention period, although these results were likely confounded by the COVID epidemic. CONCLUSION: Our findings suggest that index testing services may be beneficial in bringing PLH into treatment at an earlier stage of HIV disease and decreasing delays between HIV testing and ART initiation, potentially improving patient outcomes and retention in the HIV care cascade.

Profile of partners who completed HIV testing and received a new HIV diagnosis in Ukraine's HIV index testing program: a retrospective cohort study to inform program improvement.

BACKGROUND: Approximately one-third of people living with HIV in Ukraine are unaware of their HIV status. Index testing (IT) is an evidence-based HIV testing strategy that supports voluntary notification of partners with HIV risk, so they can receive HIV testing, prevention, and treatment services. METHODS: Ukraine scaled up IT services in 2019. This observational study of Ukraine's IT program covered 39 health facilities located in 11 regions with high HIV burden. The study used routine program data from January-December 2020 to describe the profile of named partners and explore index client (IC) and partner factors associated with two outcomes: 1) completing testing; and 2) HIV case finding. Analysis used descriptive statistics and multilevel linear mixed regression models. RESULTS: The study included 8,448 named partners, of whom 6,959 had unknown HIV status. Among them,72.2% completed HIV testing and 19.4% of those tested were newly diagnosed with HIV. Two-thirds of all new cases were among partners of ICs who were recently diagnosed and enrolled in care (< 6 months), while one third were among partners of established ICs. In adjusted analysis, partners of ICs with unsuppressed HIV viral load (VL) were less likely to complete HIV testing (adjusted odds ratio [aOR] = 0.11, p < 0.001), but more likely to receive a new HIV diagnosis (aOR = 1.92, p < 0.001). Partners of ICs who cited injection drug use or having a known HIV + partner as their own reason for testing were more likely to receive a new HIV diagnosis (aOR = 1.32, p = 0.04 and aOR = 1.71, p < 0.001 respectively). Involving providers in the partner notification process was associated with completed testing (aOR = 1.76, p = 0.001) and HIV case finding (aOR = 1.64, p < 0.01), compared with notification by ICs. CONCLUSION: HIV case detection was highest among partners of recently diagnosed ICs, but IT participation among established ICs still yielded an important share of all newly-identified HIV cases. Areas for improvement in Ukraine's IT program include completing testing for partners of ICs with unsuppressed HIV VL, with history of injection drug use or discordant partnerships. Using intensified follow-up for the sub-groups at risk of incomplete testing may be practical. Greater use of provider-assisted notification could also accelerate HIV case finding.

Introduction of the Ellavi uterine balloon tamponade into the Kenyan and Ghanaian maternal healthcare package for improved postpartum haemorrhage management: an implementation research study.

OBJECTIVES: Use of intrauterine balloon tamponades for refractory postpartum haemorrhage (PPH) management has triggered recent debate since effectiveness studies have yielded conflicting results. Implementation research is needed to identify factors influencing successful integration into maternal healthcare packages. The Ellavi uterine balloon tamponade (UBT) (Ellavi) is a new low-cost, preassembled device for treating refractory PPH. DESIGN: A mixed-methods, prospective, implementation research study examining the adoption, sustainability, fidelity, acceptability and feasibility of introducing a newly registered UBT. Cross-sectional surveys were administered post-training and post-use over 10 months. SETTING: Three Ghanaian (district, regional) and three Kenyan (levels 4-6) healthcare facilities. PARTICIPANTS: Obstetric staff (n=451) working within participating facilities. INTERVENTION: PPH management training courses were conducted with obstetric staff. PRIMARY AND SECONDARY OUTCOME MEASURES: Facility measures of adoption, sustainability and fidelity and individual measures of acceptability and feasibility. RESULTS: All participating hospitals adopted the device during the study period and the majority (52%-62%) of the employed obstetric staff were trained on the Ellavi; sustainability and fidelity to training content were moderate. The Ellavi was suited for this context due to high delivery and PPH burden. Dynamic training curriculums led by local UBT champions and clear instructions on the packaging yielded positive attitudes and perceptions, and high user confidence, resulting in overall high acceptability. Post-training and post-use, ≥79% of the trainees reported that the Ellavi was easy to use. Potential barriers to use included the lack of adjustable drip stands and difficulties calculating bag height according to blood pressure. Overall, the Ellavi can be feasibly integrated into PPH care and was preferred over condom catheters. CONCLUSIONS: The training package and time saving Ellavi design facilitated its adoption, acceptability and feasibility. The Ellavi is appropriate and feasible for use among obstetric staff and can be successfully integrated into the Kenyan and Ghanaian maternal healthcare package. TRIAL REGISTRATION NUMBERS: NCT04502173; NCT05340777.

Adolescent and Youth Experiences With Contraceptive Self-Injection in Uganda: Results From the Uganda Self-Injection Best Practices Project.

PURPOSE: We used qualitative and quantitative data to evaluate the differing experiences of adolescents and adult women in the contraceptive self-injection program in primary care settings in Uganda. From these results, we assessed barriers to adolescent DMPA-SC self-injection access and continuation and provide recommendations to address them. METHODS: The Self-Injection Best Practices (2017-2019) project in four districts trained clinic-based providers and Village Health Teams to provide self-injection training in clinics, community settings, and small group meetings for adolescent girls and young women. More than 12,000 women of reproductive age received self-injection services through the program, including 2,215 under 20 years. Structured surveys (n = 1,060) and in-depth interviews (n = 36) were conducted with randomly selected adolescent participants between July and November 2018. Mixed-effects logistic regression was used to assess quantitative differences in outcomes of interest between age groups. RESULTS: The study found no significant difference in self-injection proficiency or continuation between adolescents and adult women; 86.1% of adolescents self-injected independently when due for reinjection. Adolescents were significantly less likely than adults to report first hearing about self-injection from a community health worker. More adolescents expressed concern over discovery when seeking contraception at a clinic and fear of their DMPA-SC units being discovered at home. Adolescents were significantly less likely than adult women to mention convenience as a rationale for self-injecting, and more likely to mention wanting to learn a new skill and/or that friends recommended self-injection. DISCUSSION: Self-injection is a promising method of contraception for adolescents in Uganda, given comparable proficiency and continuation relative to adult women. Policies and programs should ensure rights-based access to a range of methods, including self-injection for this age group.

Added Value of Electronic Immunization Registries in Low- and Middle-Income Countries: Observational Case Study in Tanzania.

BACKGROUND: There is growing interest and investment in electronic immunization registries (EIRs) in low- and middle-income countries. EIRs provide ready access to patient- and aggregate-level service delivery data that can be used to improve patient care, identify spatiotemporal trends in vaccination coverage and dropout, inform resource allocation and program operations, and target quality improvement measures. The Government of Tanzania introduced the Tanzania Immunization Registry (TImR) in 2017, and the system has since been rolled out in 3736 facilities in 15 regions. OBJECTIVE: The aims of this study are to conceptualize the additional ways in which EIRs can add value to immunization programs (beyond measuring vaccine coverage) and assess the potential value-add using EIR data from Tanzania as a case study. METHODS: This study comprised 2 sequential phases. First, a comprehensive list of ways EIRs can potentially add value to immunization programs was developed through stakeholder interviews. Second, the added value was evaluated using descriptive and regression analyses of TImR data for a prioritized subset of program needs. RESULTS: The analysis areas prioritized through stakeholder interviews were population movement, missed opportunities for vaccination (MOVs), continuum of care, and continuous quality improvement. The included TImR data comprised 958,870 visits for 559,542 patients from 2359 health facilities. Our analyses revealed that few patients sought care outside their assigned facility (44,733/810,568, 5.52% of applicable visits); however, this varied by region; facility urbanicity, type, ownership, patient volume, and duration of TImR system use; density of facilities in the immediate area; and patient age. Analyses further showed that MOVs were highest among children aged <12 months (215,576/831,018, 25.94% of visits included an MOV and were applicable visits); however, there were few significant differences based on other individual or facility characteristics. Nearly half (133,337/294,464, 45.28%) of the children aged 12 to 35 months were fully vaccinated or had received all doses except measles-containing vaccine-1 of the 14-dose under-12-month schedule (ie, through measles-containing vaccine-1), and facility and patient characteristics associated with dropout varied by vaccine. The continuous quality improvement analysis showed that most quality issues (eg, MOVs) were concentrated in <10% of facilities, indicating the potential for EIRs to target quality improvement efforts. CONCLUSIONS: EIRs have the potential to add value to immunization stakeholders at all levels of the health system. Individual-level electronic data can enable new analyses to understand service delivery or care-seeking patterns, potential risk factors for underimmunization, and where challenges occur. However, to achieve this potential, country programs need to leverage and strengthen the capacity to collect, analyze, interpret, and act on the data. As EIRs are introduced and scaled in low- and middle-income countries, implementers and researchers should continue to share real-world examples and build an evidence base for how EIRs can add value to immunization programs, particularly for innovative uses.

Immunogenicity of Alternative Dosing Schedules for HPV Vaccines among Adolescent Girls and Young Women: A Systematic Review and Meta-Analysis.

Alternative dosing schedules for licensed human papilloma virus (HPV) vaccines, particularly single dose and extended intervals between doses (>12 months), are being considered to address vaccine shortages and improve operational flexibility. We searched PUBMED/MEDLINE for publications reporting immunogenicity data following administration of one of the licensed HPV vaccines (2vHPV, 4vHPV, and 9vHPV) to females aged 9-26 years. We conducted non-inferiority analyses comparing alternative to standard schedules using mixed effects meta-regression controlling for baseline HPV status and disaggregated by vaccine, subtype, time point, and age group (9-14 and 15-26 years). Non-inferiority was defined as the lower bound of the 95% confidence interval (CI) for the geometric mean titer (GMT) ratio being greater than 0.5. Our search returned 2464 studies, of which 23 were included in data analyses. When evaluated against standard schedules, although robust immunogenicity was demonstrated across all multi-dose groups, non-inferiority of extended interval dosing was mixed across vaccines, subtypes, and time points. Single dose did not meet the criteria for non-inferiority in any comparisons. Sparse data limited the number of possible comparisons, and further research is warranted.

Mental health among Ebola survivors in Liberia, Sierra Leone and Guinea: results from a cross-sectional study.

OBJECTIVES: To describe the prevalence and correlates of depression and anxiety among adult Ebola virus disease (EVD) survivors in Liberia, Sierra Leone and Guinea. DESIGN: Cross-sectional. SETTING: One-on-one surveys were conducted in EVD-affected communities in Liberia, Sierra Leone and Guinea in early 2018. PARTICIPANTS: 1495 adult EVD survivors (726 male, 769 female). PRIMARY AND SECONDARY OUTCOME MEASURES: Patient Health Questionnaire-9 (PHQ-9) depression scores and Generalised Anxiety Disorder-7 (GAD-7) scores. RESULTS: Prevalence and severity of depression and anxiety varied across the three countries. Sierra Leone had the highest prevalence of depression, with 22.0% of participants meeting the criteria for a tentative diagnosis of depression, compared with 20.2% in Liberia and 13.0% in Guinea. Sierra Leone also showed the highest prevalence of anxiety, with 10.7% of participants meeting criteria for generalized anxiety disorder (GAD-7 score ≥10), compared with 9.9% in Liberia and 4.2% in Guinea. Between one-third and one-half of respondents reported little interest or pleasure in doing things in the previous 2 weeks (range: 47.0% in Liberia to 37.6% in Sierra Leone), and more than 1 in 10 respondents reported ideation of self-harm or suicide (range: 19.4% in Sierra Leone to 10.4% in Guinea). Higher depression and anxiety scores were statistically significantly associated with each other and with experiences of health facility-based stigma in all three countries. Other associations between mental health scores and respondent characteristics varied across countries. CONCLUSIONS: Our results indicate that both depression and anxiety are common among EVD survivors in Liberia, Sierra Leone and Guinea, but that there is country-level heterogeneity in prevalence, severity and correlates of these conditions. All three countries should work to make mental health services available for survivors, and governments and organisations should consider the intersection between EVD-related stigma and mental health when designing programmes and training healthcare providers.

A Randomized Controlled Trial of the Shikamana Intervention to Promote Antiretroviral Therapy Adherence Among Gay, Bisexual, and Other Men Who Have Sex with Men in Kenya: Feasibility, Acceptability, Safety and Initial Effect Size.

Gay, bisexual, and other men who have sex with men (GBMSM) living with HIV in rights-constrained settings need support for antiretroviral therapy (ART) adherence due to barriers including stigma. The Shikamana intervention combined modified Next Step Counseling by providers with support from trained peers to improve adherence among GBMSM living with HIV in Kenya. A randomized controlled trial with 6-month follow-up was used to determine feasibility, acceptability, safety, and initial intervention effects. Generalized estimating equations examined differences in self-reported adherence and virologic suppression. Sixty men enrolled, with 27 randomly assigned to the intervention and 33 to standard care. Retention did not differ by arm, and no adverse events occurred. Feedback on feasibility and acceptability was positive based on exit interviews. After adjustment for baseline viral suppression and confounding, the intervention group had a sixfold increased odds of viral suppression during follow-up. A larger trial of a scaled-up intervention is needed.

HIV care engagement and ART adherence among Kenyan gay, bisexual, and other men who have sex with men: a multi-level model informed by qualitative research.

Gay, bisexual, and other men who have sex with men (GBMSM) are highly stigmatized and male-male sex is often criminalized in sub-Saharan Africa, impeding access to quality care for sexual health, HIV prevention, and treatment. To better understand HIV care engagement and antiretroviral therapy (ART) adherence among GBMSM in this context, a conceptual model incorporating sociocultural factors is needed. We conducted a qualitative study of barriers to and facilitators of HIV care engagement and ART adherence among Kenyan GBMSM, informed by a conceptual model based on an access, information, motivation, and behavioral skills (access-IMB) model, with trust in providers and stigma and discrimination as a priori factors of interest. We conducted 30 semi-structured interviews with HIV-positive Kenyan GBMSM, of whom 20 were taking ART and 10 had not yet initiated treatment. A deductive approach was used to confirm the relevance of basic concepts of the access-IMB model, while an inductive approach was used to identify content that emerged from men's lived experiences. Access-related information, motivation, and behavioral skills appeared relevant to HIV care engagement and ART adherence, with stigma and discrimination appearing consistently across discourse exploring facilitators and barriers. Trusted providers and supportive family and friends helped many men, and resilience-related concepts such as selective disclosure of GBMSM status, connection to lesbian, gay, bisexual, and transgender (LGBT) organizations, self-acceptance, goal-setting, social identity and altruism emerged as important facilitators. Findings suggest a need to increase support from providers and peers for Kenyan GBMSM living with HIV infection. In addition, they point toward the potential value of interventions that provide opportunities to build or enhance one's sense of community belonging in order to improve HIV care engagement and promote ART adherence for this vulnerable population.

Health Provider Views on Improving Antiretroviral Therapy Adherence Among Men Who Have Sex with Men in Coastal Kenya.

HIV-positive Kenyan men who have sex with men (MSM) are a highly stigmatized group facing barriers to care engagement and antiretroviral therapy (ART) adherence. Because care providers' views are important in improving outcomes, we sought the perspective of those serving MSM patients on how to optimize ART adherence in a setting where same-sex behavior is criminalized. We conducted 4 focus group discussions with a total of 29 healthcare workers (HCWs) experienced in providing HIV care to MSM. The semistructured, open-ended topic guide used was based on an access-information-motivation-proximal cues model of adherence, with added focus on trust in providers, stigma, and discrimination. Detailed facilitator notes and transcripts were translated into English and reviewed for common themes. The HCW identified adherence challenges of MSM patients that are similar to those of the general population, including HIV-related stigma and lack of disclosure. In addition, HCWs noted challenges specific to MSM, such as lack of access to MSM-friendly health services, economic and social challenges due to stigma, difficult relationships with care providers, and discrimination at the clinic and in the community. HCWs recommended clinic staff sensitivity training, use of trained MSM peer navigators, and stigma reduction in the community as interventions that might improve adherence and health outcomes for MSM. Despite noting MSM-specific barriers, HCWs recommended strategies for improving HIV care for MSM in rights-constrained settings that merit future research attention. Most likely, multilevel interventions incorporating both individual and structural factors will be necessary.

Depression, substance abuse and stigma among men who have sex with men in coastal Kenya.

OBJECTIVES: Mental health conditions can erode quality of life and interfere with health-related behaviours such as medication adherence. We aimed to determine the prevalence and correlates of depression and other psychosocial factors among self-identified men who have sex with men (MSM) in coastal Kenya. DESIGN: A cross-sectional survey. METHODS: Psychosocial and mental health characteristics were assessed in an audio computer-assisted self-interview (ACASI) survey among 112 MSM participating in two ongoing HIV-positive and HIV-negative cohorts in Mtwapa, Kenya. RESULTS: One-third of participants met criteria for major depressive disorder [16.1%, 95% confidence interval (95% CI) 9.8-24.2] or other depressive disorder (15.2%, 95% CI 9.1-23.2). Alcohol abuse was reported by 45% of respondents (95% CI 35.2-54.3) and other substance abuse by 59.8% (95% CI 50.1-69.0). Sexual and HIV stigma were moderate, with median scores of 11 [interquartile range (IQR) 6-17, potential range 0-33] and 25 (IQR 23-29, potential range 11-44), respectively. There were significant bivariate correlations between alcohol abuse, other substance abuse, sexual stigma and childhood and recent abuse. In a multivariable linear regression model, sexual stigma (beta = 0.17, 95% CI 0.03-0.32) and marriage to a woman (beta = -2.41 95% CI -4.74 to -0.09) were each associated with depression score. CONCLUSION: We found moderate to high levels of depression and substance abuse, and moderate levels of sexual stigma. These variables were highly inter-correlated and associated with an experience of trauma or abuse. Comprehensive mental health services are needed in this population to address these issues.