Advanced HIV Disease Management Practices within Inpatient Medicine Units at a Referral Hospital in Zambia: A Retrospective Chart Review

Background Zambia recently achieved UNAIDS 90-90-90 treatment targets for HIV epidemic control; however, inpatient facilities continue to face a large burden of patients with advanced HIV disease and HIV-related mortality. Management of advanced HIV disease, following guidelines from outpatient settings, may be more difficult within complex inpatient settings. We evaluated adherence to HIV guidelines during hospitalization, including opportunistic infection (OI) screening, treatment, and prophylaxis. Methods We reviewed inpatient medical records of people living with HIV (PLHIV) admitted to the University Teaching Hospital in Lusaka, Zambia between December 1, 20218 and April 30, 2019. We collected data on patient demographics, antiretroviral therapy (ART), HIV biomarkers, and OI screening and treatment – including tuberculosis (TB), Cryptococcus, and OI prophylaxis with cotrimoxazole (CTX). Screening and treatment cascades were constructed based on the 2017 WHO Advanced HIV Guidelines. Results We reviewed files from 200 charts of patients with advanced HIV disease; of these 92% (184/200) had been on ART previously; 58.1% (107/184) for more than 12 months. HIV viral load (VL) testing was uncommon but half of VL results were high. 39% (77/200) of patients had a documented CD4 count result. Of the 172 patients not on anti-TB treatment (ATT) on admission, TB diagnostic tests (either sputum Xpert MTB/RIF MTB/RIF or urine TB-LAM) were requested for 105 (61%) and resulted for 60 of the 105 (57%). Nine of the 14 patients (64%) with a positive lab result for TB died before results were available. Testing for Cryptococcosis was performed predominantly in patients with symptoms of meningitis. Urine TB-LAM testing was rarely performed. Conclusions Inconsistent CD4 testing reduced recognition of advanced HIV and OI screening was suboptimal, in part due to laboratory challenges. HIV programs can potentially reduce mortality and identify PLHIV with retention and adherence issues through strengthening inpatient activities, including VL testing.

Understanding Reasons for Lack of Acceptance in HIV Programs Among Indigenous: a Qualitative Study in Indonesia

Background: Melanesians are Indigenous Papuans that are racially and culturally different from most Indonesians. Poverty and inequalities remain high in this region despite having the highest revenues. Furthermore, Papua has the highest HIV prevalence rate, which is 24 times higher than other regions. Therefore, this study aimed to develop an understanding of the acceptance of HIV programs among Papuans.Methods: This is a qualitative study carried out using the grounded theory with data collected from 23 Papuans through semi-structured face-to-face interviews. All interviews were conducted in Bahasa Indonesia, audio-recorded, summarized, and transcribed for analysis.Results: The results showed that to “keep being a good Papuan," emerges from 4 interconnected categories, including 1) Culture and Religion, 2) Dealing with modernisms, 3) Tailoring program and 4) Stigma reduction. As a substantive theory underpinning the experiences of indigenous people with the programs, “Keep being a good Papuan” was a way of overcoming a series of problems and dealing with modernism to eliminating HIV. This is largely focused on the local culture, therefore any adjustment needs to balance keeping their tradition and welcoming modernism.Conclusions: Therefore, the future of the programs needs to be agreed upon, funded, implemented, measured, and achieved. One of the strategies used to achieve this is by elaborating a supportive culture and community-based interventions. Further, implementation needs to be prioritized to integrate and improve the quality of the programs due to the needs of the community and the available resources.

Spillover Effects of HIV Foreign Aid on the Delivery of Maternal and Child Health Services in Nigeria: 2008 – 2018

BackgroundThis study expands the current body of knowledge by investigating the impact of the Global Health Initiatives (GHI) on the Nigerian health system. Using robust multilevel analytic approaches, this study examined system-wide impacts of foreign aid on the Nigerian health system– a country that has witnessed substantial Development Assistance for Health disbursements in the last two decades, yet has one of the worst maternal and child health indices globally. Most of the health aid to Nigeria has been for HIV programs; and has sparked debates among stakeholders. Critics have asserted the possibility that HIV aid might not be working and could have had unintended negative consequences on the delivery of non-HIV services. Others maintained that such prioritized attention to HIV could have had a crowding-out or negative spillover effect on the delivery of other health programs in Nigeria. Thus, the focus of this study is to ascertain the nature of the spillover effect of HIV aid on the delivery of maternal and child health services in NigeriaResultsThis study identified that donor HIV financing to Nigeria increased up to 2012, and decreased steadily afterwards between 2008 – 2018. This was suggested to be linked to PEPFAR priority shift to health systems strengthening in the second round of their funding cycle. This study also identified a negative spillover effect of HIV-specific aid on the delivery of non-HIV services, and is suggested to be attributed to the prioritized attention given to HIV programs by global health systems.ConclusionsStudy findings provide systematic evidence to inform policy on the frameworks for developing a national roadmap for the effective alignment of GHIs’ coordinating mechanisms with national health priorities. Future studies should explore the effects of the Development Assistance for Health among low- and middle-income countries including Nigeria to provide evidence for policy, and substantiate how the growing interests in health systems strengthening is overcoming vertical programs and fostering systemic improvements. Government should identify turnaround strategies to strengthen Nigerian health systems for the Sustainable Development Goals, and formulate policies that improve the effectiveness of GHIs in Nigeria.

Barriers To Optimal Index Testing for Improved HIV Positivity Yield in Lusaka Urban District of Zambia - A Research Protocol

As The Proportions Of People Living With HIV Who Do Not Know Their HIV Infection Status Decrease, Reaching The Last Mile Of Those Who Are Asymptomatic And Not In Contact With The Health Care System Becomes A Critical Challenge. This Project Will Use An Explanatory Sequential Mixed-Methods Study Design. It Will Be Conducted In Three High-Volume Health Facilities In Matero Sub-District 3 Of Lusaka District In Zambia Over A Period Of One Year. The Specific Objectives Are: To Understand The Perceived Facilitators And Barriers To HIV Partner Testing From The Perspective Of The Health-Care Provider; To Propose Interventions Necessary For Improved HIV Case Finding; And To Reach High Risk But Hard To Reach Populations In HIV Programs Such As Middle-Aged Men And Adolescent Girls And Young Women (AGYW). The Permission To Conduct This Study Will Be Obtained From The Lusaka Provincial Health Office Before Its Commencement. Ethical Clearance Will Be Sought And Obtained From The ERES Converge Research Ethical Committee. The Authority To Conduct Research Will Be Sought From The National Health Research Authority. The Expected Main Findings Following The Address Of The Identified Challenges Are: Increased Number Of Recipients Of Care Indexed, Increased Index Contact Elicitation Ration From 1:1 To At Least 1:2, Improved Rate Of Contacts Tested On Time, Improved HIV Case Finding Through Index Testing, And Overall, Increased HIV Index Testing Positivity Rate From Below 25% (Baseline) To Above 40% (At The End Of The Project).

The impact of condom use on the HIV epidemic

Background: Condom promotion and supply was one the earliest interventions to be mobilized to address the HIV pandemic. Condoms are inexpensive and provide protection against transmission of HIV and other sexually transmitted diseases (STIs) as well as against unintended pregnancy. As many as 16 billion condoms may be used annually in all low- and middle-income countries (LMIC). In recent years the focus of HIV programs as been on testing and treatment and new technologies such as PrEP. Rates of condom use have stopped increasing short of UNAIDS targets and funding from donors is declining. Methods: We applied a mathematical HIV transmission model to 77 high HIV burden countries to estimate the number of HIV infections that would have occurred from 1990 to 2019 if condom use had remained at 1990 levels. Results: The results suggest that current levels of HIV would be five times higher without condom use and that the scale-up in condoms use averted about 117 million HIV infections. Conclusions: HIV programs should ensure that affordable condoms are consistently available and that the benefits of condom use are widely understood.

Health, Development, and HIV in India

The first HIV (human immunodeficiency virus) case in India was detected in 1986 among female sex workers. The rapid spread in HIV infections subsequently due mainly to high-risk behavior among vulnerable population groups required a sensitive, multisectoral, multipronged response that had to influence risk behavior and alleviate the socioeconomic impact of the epidemic. The journey has been a unique one in many ways in the history of public health in India. The challenges emanated from the economic, social, legal, and cultural contexts in which risk-taking behavior took place, and to be effective, the response required a framework that had to be vastly different from the usual public health approaches adopted in the country. The fairly successful national response was made possible due to the presence and subsequent co-option of a vibrant civil society, which shaped discussions and discourses around sex, sexuality, and gender and could reach out to marginalized and stigmatized groups with messages and interventions. During the course of the thirty years of response to the epidemic, shifts in positions of individuals in the three organs of the government—executive, legislative, and judiciary—on key sensitive issues around sexual behavior and preferences could be discerned to some extent, which was unprecedented and helped strengthen the response. New infections have come down significantly over the years and treatment has scaled up massively. However, the momentum in national HIV programs has slowed down globally and in India, with lower finances and a shift to other national priorities. The sociocultural and economic contexts have yet to change for most of the groups vulnerable to HIV, and they will continue to determine risk behavior, requiring interventions to continue at a fairly high level of intensity.

Impact of Safe Water Programs on Water Treatment Practices of People Living with Human Immunodeficiency Virus, Ethiopia, 2008

Household water chlorination has been shown to reduce diarrhea incidence among people living with Human Immunodeficiency Virus (PLHIV). Some HIV programs in Ethiopia previously provided a socially marketed chlorination product (brand name WuhaAgar) to prevent diarrhea. To evaluate the program, we compared WuhaAgar use and water treatment practices between 795 clients from 20 antiretroviral therapy (ART) clinics and 795 community members matched by age, sex, and neighborhood. Overall, 19% of study participants reported water treatment with WuhaAgar. Being an ART clinic client was associated with reported treatment of drinking water (matched odds ratios (mOR): 3.8, 95% confidence interval (CI): 2.9–5.0), reported current water treatment with WuhaAgar (mOR: 5.5, 95% CI 3.9–7.7), and bottles of WuhaAgar observed in the home (mOR: 8.8, 95% CI 5.4–14.3). Being an ART clinic client was also associated with reported diarrhea among respondents (mOR: 4.8, 95% CI 2.9–7.9) and household members (mOR:2.8, 95% CI: 1.9–4.2) in the two weeks preceding the survey. Results suggest that promoting and distributing water chlorination products in ART clinics was effective in increasing access to and use of water treatment products among PLHIV. The positive association between ART clinic attendees and diarrhea likely resulted from the immunocompromised status of ART clinic clients.