Test and treat: the early experiences in a clinic serving women at high risk of HIV infection in Kampala

Abstract

At the end of 2013, the Government of Uganda issued guidance recommending provision of AntiRetroviral Treatment (ART) to HIV-positive people in key populations, including female sex workers, regardless of CD4 cell count. We describe the implementation of this new guidance in a clinic serving women at high risk of HIV infection in Kampala. Between July and December 2015, we conducted repeat in-depth interviews with 15 women attending the clinic after the change in guidelines, to explore their perceptions regarding prompt ART initiation. The sample included some women who were HIV-negative and women who had both started and deferred ART. We conducted a data-led thematic analysis of the material from the interviews. A total of 257 of 445 eligible women had started ART; others were undecided or had not returned to the clinic after receiving the new information. Participants recounted varying experiences with the provision of prompt treatment. At an individual level, a history of treatment for opportunistic infections and other illnesses, coupled with relatively poor health, encouraged some to initiate ART promptly. However, knowledge of friends/relatives already on ART who had experienced side effects caused others to delay starting, fearing the same experience for themselves. A number of women questioned why they should start treatment when they were not sick. Situational factors such as work and residence (with many sharing single rooms) caused discomfort among newly diagnosed women who feared disclosure and stigma that would result from taking ART when they were not ill. Alcohol consumption and irregular working hours affected perceptions of future adherence, making prompt ART harder to embrace for some. Our findings show the challenges that influence the delay of treatment initiation, and/or the decision to defer receiving information on ART, with implications for the success of the test and treat programmes and guidelines.ARTICLE HISTORY

Comparative assessment of five trials of universal HIV testing and treatment in sub‐Saharan Africa

“…Besides characterizing the trial populations with standard socio‐demographic information, these trials also collect experiences and perceptions of a sample of trial participants, community members and services providers. Such qualitative research provides evidence to understand the acceptability of the UTT strategies by the general population 29, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69. Overall, the analysis of the various themes addressed within these five trials will contribute to understanding the impact of UTT strategies in various contexts as well as inform the generalization of such a strategy to new contexts.…”

Rapid initiation of antiretroviral therapy for people living with HIV

“…There remains, however, uncertainty about the long‐term treatment outcomes of rapid ART initiation (Mbonye 2016). Some concerns include insufficient adherence counselling/education; limited time to prepare psychologically for life with HIV and ART (Black 2014; Kim 2016), pill burden due to other concurrent co morbidities or conditions requiring urgent treatment (for example, tuberculosis) (Nachega 2014); and immune reconstitution inflammatory syndrome (IRIS), especially in individuals with advanced disease (CD4 counts < 200 cells/mm³) (Uthman 2015), all of which could impact on morbidity and engagement in care (Hakim 2017).…”

Test and Start for People Living With HIV and Who Use Drugs in Low and Middle Income Countries

“…53 However, the Present's Emergency Plan for AIDS Relief Scientific Advisory Board has provided recommendations regarding "Test and Start" and women's treatment programs have begun to implement "Test and Start". [54][55][56] The recommendations support the implementation of "Test and Start" initially in high volume clinics in urban areas in concert with clinical protocols that prioritize the sickest patients, as well as, provide continued access and retention for those receiving anti-retroviral treatment. Other recommendations include the importance of health care worker training and education and a public health education program for people living with HIV, peer educators, community health workers and differentiated care as part of antiretroviral treatment.…”

“…In the Uganda program, harmful alcohol consumption was perceived to be a barrier to early antiretroviral treatment due to poor adherence. 55,57 In a high resource setting, a "Test and Start" program has shown that patients who inject drugs are less likely to obtain viral suppression.…”

“…55 Health service barriers to receiving anti-retroviral treatment should be reduced with community initiated differentiated antiretroviral treatment at point of HIV testing/diagnostic sites with patient access to comprehensive care. Thus, people living with HIV are met with care and treatment based on where they are in the course of infection and with a full array of services to meet their needs.…”