Engendering health systems in response to national rollout of dolutegravir-based regimens among women of childbearing potential: a qualitative study with stakeholders in South Africa and Uganda

Alhassan, Yussif; Twimukye, Adelline; Malaba, Thokozile R; Orrell, Catherine; Myer, Landon; Waitt, Catriona; Lamorde, Mohammed; Kambugu, Andrew; Reynolds, Helen; Khoo, Saye; Taegtmeyer, Miriam

doi:10.1186/s12913-020-05580-0

Cited by 12 publications

(17 citation statements)

References 29 publications

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“…Notably, information needs vary from patient to patient. There is need for sufficient, reliable and adequate information about risks and benefits of switching to DTG among people already on ART [ 9 ]. Some patients were concerned about questions related to dosing, adverse events, and reproductive needs (Additional file 1 , Additional file 2 ).…”

Section: Discussionmentioning

confidence: 99%

“…This study builds on previous research in which researchers showed that DTG is superior to existing treatment regimens and has a more tolerable side-effect profile [ 3 ]. Drug switching was driven by the potential direct health benefits of DTG to patients over current first line EFV-based regimens [ 9 ], including increasing pre-treatment resistance to NNRTIs, fewer side effects, rapid viral suppression and low pill burden [ 22 ]. Pill burden (number of tablets taken daily or large tablet size) is associated with suboptimal adherence [ 23 ].…”

Section: Discussionmentioning

confidence: 99%

“…The initial codebook was developed after careful line-by-line analysis of the text in each transcript through open coding. We assigned codes to relevant segments of the text, and similar or related codes aggregated to form themes [ 9 ] such as positive and negative experiences of drug switching, experiences with DTG-related side effects and to develop coherent narratives. We report key phrases and verbatim quotes on the switch experience, organized by theme.…”

Section: Methodsmentioning

confidence: 99%

“…Adverse events are commonly associated with drug switching [ 8 ], but little is known about other patient experiences during the switch to DTG. Numerous challenges to drug switching are driven in part by the bottlenecks of the weak health systems of LMICs and short-time lines that have been set for transitioning patients to DTG-based ART [ 9 ]. When providers adopt guidelines, participants may experience new challenges to adherence after switching from EFV or NVP-based ART to DTG-based ART [ 6 ].…”

Section: Introductionmentioning

confidence: 99%

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Patient experiences of switching from Efavirenz- to Dolutegravir-based antiretroviral therapy: a qualitative study in Uganda

et al. 2021

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Background In 2019, the World Health Organisation (WHO) recommended Dolutegravir (DTG) as the preferred first-line antiretroviral treatment (ART) for all persons with HIV. ART regimen switches may affect HIV treatment adherence. We sought to describe patient experiences switching from EFV to DTG-based ART in Kampala, Uganda. Methods Between July and September 2019, we purposively sampled adults living with HIV who had switched to DTG at the Infectious Diseases Institute HIV clinic. We conducted in-depth interviews with adults who switched to DTG, to explore their preparation to switch and experiences on DTG. Interviews were audio-recorded, transcribed and analysed thematically using Atlas ti version 8 software. Results We interviewed 25 adults: 18 (72%) were women, and the median age was 35 years (interquartile range [IQR] 30–40). Median length on ART before switching to DTG was 67 months (IQR 51–125). Duration on DTG after switching was 16 months (IQR 10–18). Participants reported accepting provider recommendations to switch to DTG mainly because they anticipated that swallowing a smaller pill once a day would be more convenient. While most participants initially felt uncertain about drug switching, their providers offer of frequent appointments and a toll-free number to call in the event of side effects allayed their anxiety. At the same time, participants said they felt rushed to switch to the new ART regimen considering that they had been on their previous regimen(s) for several years and the switch to DTG happened during a routine visit when they had expected their regular prescription. Some participants felt unprepared for new adverse events associated with DTG and for the abrupt change in treatment schedule. Most participants said they needed additional support from their health providers before and after switching to DTG. Conclusion and recommendations Adults living with HIV stable on an EFV-based regimen but were switched to DTG in a program-wide policy change found the duration between counselling and drug switching inadequate. DTG was nonetheless largely preferred because of the small pill size, once daily dosing, and absence of EFV-like side effects. Community-engaged research is needed to devise acceptable ways to prepare participants for switching ART at scale.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Patient experiences of switching from Efavirenz- to Dolutegravir-based antiretroviral therapy: a qualitative study in Uganda

et al. 2021

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“…As LMICs roll-out dolutegravir-based regimens in their HIV treatment programmes, a key question is how communities perceive the risks and benefits of the transition. The potential risks of dolutegravir in pregnancy could profoundly influence community acceptability and attitudes towards its use in women of childbearing age [ 19 ]. Women may lack accessible information and services and may face difficulties in decision-making despite WHO guidelines emphasising individual choice.…”

Section: Introductionmentioning

confidence: 99%

Community acceptability of dolutegravir-based HIV treatment in women: a qualitative study in South Africa and Uganda

et al. 2020

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Background Despite concerns about dolutegravir use in pregnancy, most low- and middle-income countries are accelerating the introduction of dolutegravir-based regimens into national antiretroviral treatment programmes. Questions remain about the acceptability of dolutegravir use in women due to the potential risks in pregnancy. This study from South Africa and Uganda explored community values, preferences and attitudes towards the use of dolutegravir-based regimens in women. Methods This study employed a qualitative design involving in-depth interviews and focus group discussion conducted between August 2018 to March 2019. The study was conducted in the months following an announcement of a potential risk for neural tube defects with dolutegravir use among women during conception and the first trimester. Participants included HIV positive pregnant and lactating women and their partners. They were selected purposively from urban poor communities in South Africa and Uganda. Data was analysed thematically in NVivo. Results Forty-four in-depth interviews and 15 focus group discussions were conducted. Most participants had positive views of dolutegravir-based regimens and perceived it to be more desirable compared with efavirenz-containing regimens. There was widespread concern about use of dolutegravir during pregnancy and among women of childbearing age due to publicity around the possible association with neural tube defects. Acceptability was gendered, with nearly all male participants preferring their female spouses of childbearing potential not to use dolutegravir, while most women not planning pregnancy wanted access to contraception alongside dolutegravir. Community awareness and knowledge of dolutegravir was low and characterised by negative information. Women were concerned about HIV-related stigma and wanted the privacy features of dolutegravir to be strengthened with modification of the pill appearance and disguised packaging. Conclusions Dolutegravir-based regimens were found to be generally acceptable for use in women except during pregnancy. Interest in a dolutegravir-based regimen was linked with its perceived potential to enhance health, privacy and reduce stigma while concerns about neural tube defects were the main potential barrier to dolutegravir uptake in women. In order to optimise the community acceptability and uptake of acceptability-based regimen among women it is critical to strengthen community awareness and understanding of dolutegravir treatment, improve contraception services alongside the introduction of dolutegravir, and engage with male partners.

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Contraception use and HIV outcomes among women initiating dolutegravir‐containing antiretroviral therapy in Kenya: a retrospective cohort study

et al. 2022

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Introduction The rollout of dolutegravir (DTG) in low‐ and middle‐income countries was disrupted by a potential association reported with periconceptional DTG exposure among women living with HIV (WLHIV) and infant neural tube defects. This prompted countries to issue interim guidance limiting DTG use among women of reproductive potential to those on effective contraception. Data to understand the potential impact of such guidance on WLHIV are limited. Methods We conducted a retrospective cohort analysis of WLHIV 15–49 years initiating DTG‐containing antiretroviral treatment (ART) in Kenya from 2017 to 2020. We determined baseline effective (oral, injectable or lactational amenorrhea) and very effective (implant, intrauterine device or female sterilization) contraception use among women who initiated DTG before (Group 1) or during (Group 2) the interim guideline period. We defined incident contraception use in each group as the number of contraceptive methods initiated ≤180 days post‐guideline (Group 1) or post‐DTG initiation (Group 2). We determined the proportions of all women who switched from DTG‐ to non‐nucleoside reverse transcriptase inhibitor (NNRTI)‐ (efavirenz or nevirapine) containing ART ≤12 months post‐DTG initiation, compared their viral suppression (<1000 copies/ml) and conducted multivariable logistic regression to determine factors associated with switching from DTG to NNRTI‐containing ART. Results Among 5155 WLHIV in the analysis (median age 43 years), 89% initiated DTG after transitioning from an NNRTI. Baseline effective and very effective contraception use, respectively, by the group were: Group 1 (12% and 13%) and Group 2 (41% and 35%). Incident contraception use in each group was <5%. Overall, 498 (10%) women switched from DTG to an NNRTI. Viral suppression among those remaining on DTG versus switched to NNRTI was 95% and 96%, respectively (p = 0.63). In multivariable analysis, incident effective and very effective contraception use was not associated with switching. Conclusions Baseline, but not incident, effective contraception use was higher during the interim guideline period compared to before it, suggesting women already using effective contraception were preferentially selected to initiate DTG after the guideline was released. These findings reveal challenges in the implementation of policy which ties antiretroviral access to contraceptive use. Future guidance should capture nuances of contraception decision‐making and support women's agency to make informed decisions.

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Engendering health systems in response to national rollout of dolutegravir-based regimens among women of childbearing potential: a qualitative study with stakeholders in South Africa and Uganda

Cited by 12 publications

References 29 publications

Patient experiences of switching from Efavirenz- to Dolutegravir-based antiretroviral therapy: a qualitative study in Uganda

Patient experiences of switching from Efavirenz- to Dolutegravir-based antiretroviral therapy: a qualitative study in Uganda

Community acceptability of dolutegravir-based HIV treatment in women: a qualitative study in South Africa and Uganda

Contraception use and HIV outcomes among women initiating dolutegravir‐containing antiretroviral therapy in Kenya: a retrospective cohort study

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