Pregnancy desire and dual method contraceptive use among people living with HIV attending clinical care in Kenya, Namibia and Tanzania.

AIM: To describe factors associated with pregnancy desire and dual method use among people living with HIV in clinical care in sub-Saharan Africa. DESIGN: Sexually active HIV-positive adults were enrolled in 18 HIV clinics in Kenya, Namibia and Tanzania. Demographic, clinical and reproductive health data were captured by interview and medical record abstraction. Correlates of desiring a pregnancy within the next 6 months, and dual method use [defined as consistent condom use together with a highly effective method of contraception (hormonal, intrauterine device (IUD), permanent)], among those not desiring pregnancy, were identified using logistic regression. RESULTS: Among 3375 participants (median age 37 years, 42% male, 64% on antiretroviral treatment), 565 (17%) desired a pregnancy within the next 6 months. Of those with no short-term fertility desire (n=2542), 686 (27%) reported dual method use, 250 (10%) highly effective contraceptive use only, 1332 (52%) condom use only, and 274 (11%) no protection. Respondents were more likely to desire a pregnancy if they were from Namibia and Tanzania, male, had a primary education, were married/cohabitating, and had fewer children. Factors associated with increased likelihood of dual method use included being female, being comfortable asking a partner to use a condom, and communication with a health care provider about family planning. Participants who perceived that their partner wanted a pregnancy were less likely to report dual method use. CONCLUSIONS: There was low dual method use and low use of highly effective contraception. Contraceptive protection was predominantly through condom-only use. These findings demonstrate the importance of integrating reproductive health services into routine HIV care.

Qualitative assessment of the integration of HIV services with infant routine immunization visits in Tanzania.

BACKGROUND: In 2009, a project was implemented in 8 primary health clinics throughout Tanzania to explore the feasibility of integrating pediatric HIV prevention services with routine infant immunization visits. METHODS: We conducted interviews with 64 conveniently sampled mothers of infants who had received integrated HIV and immunization services and 16 providers who delivered the integrated services to qualitatively identify benefits and challenges of the intervention midway through project implementation. FINDINGS: Mothers' perceived benefits of the integrated services included time savings, opportunity to learn their child's HIV status and receive HIV treatment, if necessary. Providers' perceived benefits included reaching mothers who usually would not come for only HIV testing. Mothers and providers reported similar challenges, including mothers' fear of HIV testing, poor spousal support, perceived mandatory HIV testing, poor patient flow affecting confidentiality of service delivery, heavier provider workloads, and community stigma against HIV-infected persons; the latter a more frequent theme in rural compared with urban locations. INTERPRETATION: Future scale-up should ensure privacy of these integrated services received at clinics and community outreach to address stigma and perceived mandatory testing. Increasing human resources for health to address higher workloads and longer waiting times for proper patient flow is necessary in the long term.

HIV prevention in care and treatment settings: baseline risk behaviors among HIV patients in Kenya, Namibia, and Tanzania.

UNLABELLED: HIV care and treatment settings provide an opportunity to reach people living with HIV/AIDS (PLHIV) with prevention messages and services. Population-based surveys in sub-Saharan Africa have identified HIV risk behaviors among PLHIV, yet data are limited regarding HIV risk behaviors of PLHIV in clinical care. This paper describes the baseline sociodemographic, HIV transmission risk behaviors, and clinical data of a study evaluating an HIV prevention intervention package for HIV care and treatment clinics in Africa. The study was a longitudinal group-randomized trial in 9 intervention clinics and 9 comparison clinics in Kenya, Namibia, and Tanzania (N = 3538). Baseline participants were mostly female, married, had less than a primary education, and were relatively recently diagnosed with HIV. Fifty-two percent of participants had a partner of negative or unknown status, 24% were not using condoms consistently, and 11% reported STI symptoms in the last 6 months. There were differences in demographic and HIV transmission risk variables by country, indicating the need to consider local context in designing studies and using caution when generalizing findings across African countries. Baseline data from this study indicate that participants were often engaging in HIV transmission risk behaviors, which supports the need for prevention with PLHIV (PwP). TRIAL REGISTRATION: ClinicalTrials.gov NCT01256463.

Clinical and behavioural aspects of aging with HIV infection.

Scant attention has been paid to the effects of ageing and HIV. This study examined age distribution and explored the impact of age on the experience of illness. One thousand and seven consecutive attenders at five UK HIV clinics were approached, 904 met inclusion criteria and 778 agreed to participate (86% response rate). They provided detailed information on demographics, experience of illness, physical and psychological symptoms, quality of life, treatment experience and doctor-patient communications. Twelve percent were aged over 50. There were significantly more males in the over 50s (86% vs. 75%), more gay males x(2) = 7, p = 0.04 and fewer females (14% vs. 25%) x(2) = 5; p = 0.03. No significant differences were found on measures of education, employment or migration status or physical symptom experience. The older group had significantly lower psychological and global burden scores and were more likely to take antiretrovirals (88% vs. 79%; p = 0.04). Triggers for treatment switching showed older participants significantly less burdened by food restrictions, pill burden, taste, nausea, diarrhoea, sleep disturbance, concentration problems, anxiety depression, skin rashes, liver complaints or a need for a simpler regimen. The older group were similar in employment, education and disclosure, but complained less and reported much higher tolerance.

United Kingdom acquisition of HIV infection in African residents in London: more than previously thought.

Between a quarter to a third of HIV-positive African residents in the UK, and nearly half of HIV-positive African men who have sex with men, may have acquired their HIV infection in the UK, which is substantially higher than previously estimated. These estimates are likely to worsen given the increasing HIV prevalence and assortative sexual mixing in this community, especially among heterosexuals. HIV prevention interventions for Africans must focus on reducing transmission within the UK as well as addressing infections acquired abroad.

Suicidal ideation in UK HIV clinic attenders.

BACKGROUND: HIV has been associated with elevated suicidal ideation. Although new treatments have changed prognosis, they also bring new challenges. This study measured suicidal ideation in HIV clinic attenders in the United Kingdom (London/Southeast) and explored associated factors. METHOD: All 1006 attenders at five HIV clinics were approached, of which 903 met inclusion criteria and 778 participated (86% response). Participants provided detailed information on suicidal ideation, demographics, treatment, adherence, symptoms (psychological and physical on Memorial Symptom Assessment Schedule), quality of life (EuroQol) information, HIV disclosure, clinical variables, sexual risk behaviour and treatment optimism. RESULTS: There was a 31% prevalence of suicidal ideation. Factors associated with suicidal ideation were being a heterosexual man, black ethnicity, unemployment, lack of disclosure of HIV status, having stopped antiretroviral treatment (compared to treatment or treatment naive), physical symptoms, psychological symptoms and poorer quality of life. There was no association with sexual risk behaviour. Sex/sexuality and ethnicity were independently associated with suicidal ideation: the odds of suicidal ideation increased almost two-fold for heterosexual men compared with gay men or women and for black respondents compared with White or Asian respondents. Lack of disclosure was independently associated with a two-fold increase in odds of suicidal ideation. Elevated physical and psychological symptoms were strong independent predictors of suicidal ideation. Independent predictors of suicidal ideation were very similar among the subgroup of 492 patients on antiretroviral treatment. CONCLUSION: Despite advances in treatment, suicidal ideation rates among HIV-positive clinic attenders are high. Emotional support and attention to mental health provision and social context are strongly endorsed.

Adherence to antiretroviral treatment in patients with HIV in the UK: a study of complexity.

Adherence to HIV treatment regimes is a core element to viral suppression. Yet measurement of adherence is complex. Although adherence levels are good predictors of outcome, they do not always provide full explanations of observed variations in responses. This study was set up to examine the complexity of adherence measurement and to examine rates of adherence in the presence of complex measurement. A total of 502 consecutive attenders at HIV clinics in the UK (80.5% response rate) provided detailed measurement on adherence in the preceding 7 days, setting out dose adherence, as well as measures of timing and dietary conditions. In addition, a range of psychological, demographic and relationship data were gathered to understand predictors of full and partial adherence. Although 79.1% reported dose adherence in the previous 7 days, 42.8% had not taken the dose at the correct time, and 27.2% had not taken the dose under the correct circumstances. Using a more complex composite measure of full adherence, rates reduced from 79.1% to 41.5%. Comparisons of those deemed fully adherent, partially adherent and non-adherent were carried out. Those that were fully adherent were significantly more likely to be older (F=7.8, p<0.001), UK born (F=6.8, p=0.03), code ethnicity as white (F=5.3, p=0.07), record higher quality of life (chi(2)=8.7, p=0.01), lower psychological symptoms (chi(2)=15.2, p=0.001) and lower global distress symptoms (chi(2)=6.9, p=0.03). There were no differences according to education, behavioural and attitudinal variables (disclosure, stable relationship, STI diagnosed, number of sexual partners, unprotected sex, optimism or treatment switching). Fully adherent groups were significantly more likely to be in agreement with their doctor on treatment initiation (chi(2)=6.2, p=0.045), satisfied with the amount of involvement in the decision-making process (chi(2)=7.3, p=.026), their wishes were considered (chi(2)=12.5, p=0.002) and had monitoring of their condition (chi(2)=7.1, p=0.028). Multivariate analysis showed that variables which contributed significantly at a 5% criterion level to complex adherence were physical symptoms (OR=0.56, p=0.05), psychological symptoms (OR=2.37, p<0.001), age (OR=0.96, p=0.02), education (OR=0.54, p=0.03), having more than one sexual partner (OR=0.46, p=0.03), having risky sex (OR=4.30, p=0.002) and being optimistic about treatments (OR=0.42, p=0.01). The softer markers of adherence are not usually measured in follow up and may account for variations in treatment responses. The complexity of adherence needs to be understood and addressed to maximise treatment efficacy.

Successive switching of antiretroviral therapy is associated with high psychological and physical burden.

HIV treatment and management is constantly evolving. This is as a result of more treatment options coming on stream, tolerance changes and progress in treatment management. HIV infection today, in resource-rich countries and in the presence of combination therapies, is experienced as lifelong treatment punctuated by adjustments to antiretroviral therapy (ART) regimens. People who are diagnosed as HIV positive face a number of challenges and changes around the decision to commence treatment, responses to treatment and changes in treatment regimens. This study was set up to examine the experience of switching treatments and the impact of such switches on psychological parameters. The method used was a cross-sectional questionnaire study. A group of 779 HIV-positive clinic attendees at four clinics in London and South East England participated in the study (86% response rate). They provided detail of their treatment switching experiences as well as demographic details, risk and optimism evaluations, quality of life, symptom burden, adherence and disclosure information. The sample (n=779) comprised 183 (24%) females, 76 (10%) heterosexual males and 497 gay males (66%). Self-reported ethnicity was 67% white, 25% black, 3% Asian and 5% mixed/other ethnicity. One hundred and fifty-five (21%) were ART-naïve and 624 (79%) were ART experienced; 161 (22%) were receiving their first regimen, 135 (18%) had experienced one regimen switch, 196 (26%) had multiple switches and 99 (13.3%) had stopped treatment. Treatment naïve, non-switchers and single switchers generally reported lower symptom burden and higher quality of life. Multiple switchers reported higher physical symptom burden and higher global symptom distress scores. Those who had stopped treatment had significantly lower quality-of-life scores than all other groups. Suicidal ideation was high across the groups and nearly a fifth of all respondents had not disclosed their HIV status to anyone. Reported adherence was suboptimal -- 79% of subjects were at least 95% adherent on self-report measures of doses taken over the preceding week. In conclusion, nearly half this clinic sample will have switched treatments. A holistic approach is needed to understand the psychological effects of such switches if lifelong treatment is to be maintained and those on antiretroviral treatment are to attain good quality of life and minimize symptom burden.

Divergent approaches to partner notification for sexually transmitted infections across the European union.

OBJECTIVE: The objective of this study was to characterize partner notification (PN) policy and practice for sexually transmitted infections (STIs) in the European Union (EU) and Norway. GOAL: The goal of this study was to promote European good practice in PN. STUDY: This study consisted of a cross-sectional survey using a structured questionnaire to national STI surveillance leads. RESULTS: Considerable heterogeneity exists in approaches to PN. In 2 countries, PN is compulsory for notifiable STIs; and in 13, it is voluntary. Most countries use patient referral but 5 of 15 also offer provider referral. Activity level varies by country and disease. Etiologic treatment of contacts is most common; 5 usually offer epidemiologic treatment and patient-expedited treatment is unusual. Similarities exist with provision mainly by specialized STI treatment services for bacterial STIs. CONCLUSIONS: This divergence in approach calls for the setting of minimum standards for PN delivery together with mechanisms for establishing and sharing best practice. Further research must identify monitoring systems for inclusion in routine surveillance.

The role for government health centers in provision of same-day voluntary HIV counseling and testing in Kenya.

OBJECTIVE: To explore the role of primary health centers in provision of voluntary counseling and testing (VCT) in Kenya. DESIGN AND SETTING: Prospective service evaluation at 3 (1 urban and 2 rural) government health centers. SUBJECTS: Consecutive adult clients. MAIN OUTCOME MEASURES: Uptake of services, user characteristics, quality of service. RESULTS: Counseling services received 2315 new clients over 26 months. The last quarter averaged 101 clients per clinic. More than 80% of clients lived locally. Overall 93% opted to test, 91% receiving results, 82% on the same day. Most clients tested HIV negative (81%). Youth and men were well represented. Few couples (10%) attended. Seventeen percent of women were pregnant. Self-referral was common and illness was an uncommon reason for testing (<20%). Thirty-one percent of clients were referred from VCT to other health center services. Counseling was perceived as high quality by users and providers. Validation of the test algorithm showed a sensitivity of 98.0% and specificity of 98.7%. CONCLUSION: Government health centers in Kenya can be appropriate providers of VCT. This pilot helped initiate a new strategy of health center-based VCT in Kenya and this has facilitated rapid expansion and more equitable provision for Kenyans.

Assessing the cost and willingness to pay for voluntary HIV counselling and testing in Kenya.

OBJECTIVE: Voluntary counselling and testing (VCT) should be an important component in a country's HIV/AIDS prevention and care strategy. However, the high cost of VCT raises concerns about the affordability of VCT in low-income countries. This study was designed to assess the costs of VCT and to identify potential ways of introducing VCT more affordably. METHODOLOGY: An economic evaluation was performed of VCT services in two rural health centres in Thika District and an urban health centre in Nairobi, Kenya. A contingent valuation study was also performed among VCT clients. Estimates were developed regarding the national cost of offering VCT services in Kenya. RESULTS: VCT added US dollars 6800 per year to the average cost of providing services at each of these three health centres. The evaluation revealed that the incremental cost, from the government's perspective, of adding VCT is approximately 16 dollars per client. The estimated incremental cost per client is significantly less than a previous cost estimate in Kenya which estimated a cost per client of 26 dollars. The difference in cost estimates is in part attributable to the emphasis of this project on integrating VCT services into existing health centres, rather than creating stand-alone sites. The cost of VCT services might be further reduced to as little as 8 dollars per client if a government health worker could perform the counselling. A contingent valuation study indicated that most VCT clients would be willing to pay at least 2 dollars for the service. However, if the full cost of the service were charged to the client, less than 5% of clients indicated they were willing and able to pay for the service. CONCLUSIONS: Integrating services into existing health centres can significantly reduce the cost of VCT. Additional cost reductions may be feasible if health centre staff are hired to perform the counselling. Furthermore, it appears that some level of cost recovery from VCT clients is feasible and can contribute to sustainability, although it is very unlikely that the full cost of the service could be recovered from the clients. The national provision of VCT in all Kenyan health centres is likely to be an affordable option, although additional operational research is required to determine the most appropriate way of scaling up VCT services throughout the country.

Costs of hospital care for HIV-positive and HIV-negative patients at Kenyatta National Hospital, Nairobi, Kenya.

OBJECTIVE: To record the costs of hospital care for HIV-positive and -negative patients in Nairobi, and identify costs paid by patients per admission. DESIGN: Cost data were collected on inpatients enrolled in a linked clinical study using standardized costing methods. SETTING: Kenyatta National Hospital, Nairobi's main district hospital. PATIENTS: Consecutive adult medical admissions to one ward over 14 weeks who consented to enrollment; tertiary referrals were excluded. MAIN OUTCOME MEASURE: Average length of stay and cost per patient admission. RESULTS: The hospital costs of 398 patients (163 HIV positive; 33 with clinical AIDS) were analysed. The mean length of stay was 9.3 days and the mean cost per patient admission was US$163. There was no significant difference in costs or mean lengths of stay between HIV-positive and -negative groups, nor were the costs and lengths of stay for clinical AIDS patients significantly different to those for HIV-positive patients without AIDS. The patient charges paid to the hospital per admission, recorded for 344 patients, were on average US$61; and did not differ by HIV status. CONCLUSION: The similar cost patterns for inpatient care irrespective of HIV status or clinical AIDS probably reflects the limited provision of care beyond basic clinical services. Length of stay rather than differing treatment regimes thus appears to be the main cost driver. Private costs of medical care were high and were likely to pressurize households. When resources are limited, the introduction of new, more costly therapies needs careful planning. The study provides cost information for planning care services in resource-poor settings.