Optimizing Test and Treat in Malawi: health care worker perspectives on barriers and facilitators to ART initiation among HIV-infected clients who feel healthy

Dovel, Kathryn; Phiri, Khumbo; Mphande, Misheck; Mindry, Deborah; Sanudi, Esnart; Bellos, Mcdaphton; Hoffman, Risa M.

doi:10.1080/16549716.2020.1728830

Cited by 21 publications

(20 citation statements)

References 45 publications

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“…We found that primary care providers were knowledgeable about the UTT and SDI policies, and generally regarded them positively, highlighting the clinical and public health benefits. Similar opinions were shared by health care providers in high-income and other LMIC settings during ART eligibility expansion from a CD4 of 350-500 cells/µl, and after UTT policy adoption, and likewise among those implementing the Option B+ strategy of universal-testing and initiation of lifelong ART among all HIV-positive pregnant and breastfeeding women [26][27][28][29][30][31].…”

Section: Discussionmentioning

confidence: 89%

Health provider perspectives on the implementation of the same-day-ART initiation policy in the Gauteng province of South Africa

Onoya

Mokhele

Sineke

et al. 2021

Health Res Policy Sys

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Background In September 2016, South Africa (SA) began implementing the universal-test-and-treat (UTT) policy in hopes of attaining the UNAIDS 90-90-90 targets by 2020. The SA National Department of Health provided a further directive to initiate antiretroviral therapy (ART) on the day of HIV diagnosis in September 2017. We conducted a qualitative study to determine the progress in implementing UTT and examine health providers' perspectives on the implementation of the same-day initiation (SDI) policy, six months after the policy change. Methods We conducted in-depth interviews with three professional nurses, and four HIV lay counsellors of five primary health clinics in the Gauteng province, between October and December 2017. In September 2018, we also conducted a focus group discussion with ten professional nurses/clinic managers from ten clinic facilities. The interviews and focus groups covered the adoption and implementation of UTT and SDI policies. Interviews were conducted in English, Sotho or Zulu and audio-recorded with participant consent. Audio-recordings were transcribed verbatim, translated to English and analysed thematically using NVivo 11. Results The data indicates inconsistencies across facilities and incongruities between counsellor and nursing provider perspectives regarding the SDI policy implementation. While nurses highlighted the clinical benefits of early ART initiation, they expressed concerns that immediate ART may be overwhelming for some patients, who may be unprepared and likely to disengage from care soon after the initial acceptance of ART. Accordingly, the SDI implementation was slow due to limited patient demand, provider ambivalence to the policy implementations, as well as challenges with infrastructure and human resources. The process for assessing patient readiness was poorly defined by health providers across facilities, inconsistent and counsellor dependent. Providers were also unclear on how to ensure that patients who defer treatment return for ongoing counselling. Conclusions Our results highlight important gaps in the drive to achieve the ART initiation target and demonstrate the need for further engagement with health care providers around the implementation of same-day ART initiation, particularly with regards to infrastructural/capacity needs and the management of patient readiness for lifelong ART on the day of HIV diagnosis. Additionally, there is a need for improved promotion of the SDI provision both in health care settings and in media communications to increase patient demand for early and lifelong ART.

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Section: Discussionmentioning

confidence: 89%

Health provider perspectives on the implementation of the same-day-ART initiation policy in the Gauteng province of South Africa

Onoya

Mokhele

Sineke

et al. 2021

Health Res Policy Sys

View full text Add to dashboard Cite

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“…Denial contributes to commencing treatment late and poor adherence to ART when it is commenced [ 13 ]. Association among perceived risk to HIV infection, sexual risk behaviours and treatment adherence has been described in previous studies [ 13 , 14 ]. However, there is limited knowledge on the factors associated with HIV perceived risk and rapid ART initiation.…”

Section: Introductionmentioning

confidence: 69%

Effect of perceived HIV risk on initiation of antiretroviral therapy during the universal test and treat era in South Africa

et al. 2021

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Background South Africa has not achieved the 90–90–90 goals, in part due to low rates of antiretroviral therapy (ART) initiation among those aware of their HIV status. Perceived risk of HIV at the time of testing may affect likelihood of rapid ART initiation. The purpose of this study was to evaluate factors associated with perceived risk of HIV and the relationship between perceived HIV risk and rapid ART initiation during the universal test and treat era which was adapted in October 2016. Methods We conducted a prospective study of adults undergoing HIV testing from October 2016–February 2019 at Ithembalabantu Clinic in Durban. Eligible participants reported not previously being diagnosed with HIV. Before HIV testing, participants were asked to assess their perceived HIV risk on a four-level scale. We categorized “definitely not” and “probably not going to acquire HIV” as a low perceived risk, and “probably will” and “definitely will become HIV-infected” as a high perceived risk of HIV infection. Participants were followed for up to 14 months following HIV testing to assess ART initiation. Results Among 1519 people newly diagnosed with HIV, 55% were female and mean age was 33 years. Among those, 1382 (90.9%) had a high HIV risk perception and 137 (9.1%) reported low HIV risk perception. In the low risk group individuals were more likely to be female (58% vs 55%), unemployed (62% vs 59%), have a partner with unknown HIV status (61% vs 55%) compared to the high risk group. 83.2% of those with low HIV risk perception reported previously HIV testing compared 91.5% of those with high HIV risk perception. In the multivariate model, males were associated with a higher chances of initiating ART compared to females (adjusted hazard ratio (aHR): 1.187, CI 1.187 (1.060–1.329) and being unemployed (aHR 0.767 CI (0.650–0.905). Those with a low HIV risk perception were less likely to initiate ART 125 (91%) vs 1310 (95%) p = 0.022), and took longer to initiate on ART after HIV diagnosis (11 days’ vs 4 days, p = 0.042). Conclusion Factors associated with high HIV risk perception included being unemployed, single, and having a partner of unknown HIV status. People living with HIV (PLHIV) in South Africa who had a low self-perceived risk to HIV infection were less likely to initiate ART. Assessing self-perceived risk of HIV infection may help direct counselling and improve ART initiation to achieve universal 90–90–90 goal.

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“…At the social network as well as societal level, policies emphasizing the collective benefits of Treat All could increase buy-in of early ART and facilitate the transition from diagnosis to successful engagement in care. A study examining health care worker perspectives on Treat All suggested community-wide education on benefits of early ART to increase awareness would facilitate ART initiation [ 42 ]. Many participants in our study were aware of the benefits of initiating ART early with respect to their own and others’ health and expressed a high degree of support for Treat All as a national policy.…”

Section: Discussionmentioning

confidence: 99%

How early is too early? Challenges in ART initiation and engaging in HIV care under Treat All in Rwanda—A qualitative study

et al. 2021

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Introduction HIV treatment guidelines recommend that all people living with HIV (PLWH) initiate antiretroviral therapy (ART) as soon as possible after diagnosis (Treat All). As Treat All is more widely implemented, an increasing proportion of PLWH are likely to initiate ART when they are asymptomatic, and they may view the relative benefits and risks of ART differently than those initiating at more advanced disease stages. To date, patient perspectives of initiating care under Treat All in sub-Saharan Africa have not been well described. Methods From September 2018 to March 2019, we conducted individual, semi-structured, qualitative interviews with 37 patients receiving HIV care in two health centers in Kigali, Rwanda. Data were analyzed using a mixed deductive and inductive thematic analysis approach to describe perceived barriers to, facilitators of and acceptability of initiating and adhering to ART rapidly under Treat All. Results Of 37 participants, 27 were women and the median age was 31 years. Participants described feeling traumatized and overwhelmed by their HIV diagnosis, resulting in difficulty accepting their HIV status. Most were prescribed ART soon after diagnosis, yet fear of lifelong medication and severe side effects in the immediate period after initiating ART led to challenges adhering to therapy. Moreover, because many PLWH initiated ART while healthy, taking medications and attending appointments were visible signals of HIV status and highly stigmatizing. Nonetheless, many participants expressed enthusiasm for Treat All as a program that improved health as well as health equity. Conclusion For newly-diagnosed PLWH in Rwanda, initiating ART rapidly under Treat All presents logistical and emotional challenges despite the perceived benefits. Our findings suggest that optimizing early engagement in HIV care under Treat All requires early and ongoing intervention to reduce trauma and stigma, and promote both individual and community benefits of ART.

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Optimizing Test and Treat in Malawi: health care worker perspectives on barriers and facilitators to ART initiation among HIV-infected clients who feel healthy

Cited by 21 publications

References 45 publications

Health provider perspectives on the implementation of the same-day-ART initiation policy in the Gauteng province of South Africa

Health provider perspectives on the implementation of the same-day-ART initiation policy in the Gauteng province of South Africa

Effect of perceived HIV risk on initiation of antiretroviral therapy during the universal test and treat era in South Africa

How early is too early? Challenges in ART initiation and engaging in HIV care under Treat All in Rwanda—A qualitative study

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