Uninterrupted HIV treatment for women: Policies and practices for care transitions during pregnancy and breastfeeding in Côte d’Ivoire, Lesotho and Malawi

Transitions between services for continued antiretroviral treatment (ART) during and after pregnancy are a commonly overlooked aspect of the HIV care cascade, but ineffective transitions can lead to poor health outcomes for women and their children. In this qualitative study, we conducted interviews with 15 key stakeholders from Ministries of Health along with PEPFAR-supported and other in-country non-governmental organizations actively engaged in national programming for adult HIV care and prevention of mother-to-child-transmission of HIV (PMTCT) services in Côte d’Ivoire, Lesotho and Malawi. We aimed to understand perspectives regarding transitions into and out of PMTCT services for continued ART. Thematic analysis revealed that, although transitions of care are necessary and a potential point of loss from ART care in all three countries, there is a lack of clear guidance on transition approach and no formal way of monitoring transition between services. Several opportunities were identified to monitor and strengthen transitions of care for continued ART along the PMTCT cascade.

Integrating HIV services and other health services: A systematic review and meta-analysis

Background Integration of HIV services with other health services has been proposed as an important strategy to boost the sustainability of the global HIV response. We conducted a systematic and comprehensive synthesis of the existing scientific evidence on the impact of service integration on the HIV care cascade, health outcomes, and cost-effectiveness. Methods and findings We reviewed the global quantitative empirical evidence on integration published between 1 January 2010 and 10 September 2021. We included experimental and observational studies that featured both an integration intervention and a comparator in our review. Of the 7,118 unique peer-reviewed English-language studies that our search algorithm identified, 114 met all of our selection criteria for data extraction. Most of the studies (90) were conducted in sub-Saharan Africa, primarily in East Africa (55) and Southern Africa (24). The most common forms of integration were (i) HIV testing and counselling added to non-HIV services and (ii) non-HIV services added to antiretroviral therapy (ART). The most commonly integrated non-HIV services were maternal and child healthcare, tuberculosis testing and treatment, primary healthcare, family planning, and sexual and reproductive health services. Values for HIV care cascade outcomes tended to be better in integrated services: uptake of HIV testing and counselling (pooled risk ratio [RR] across 37 studies: 1.67 [95% CI 1.41–1.99], p < 0.001), ART initiation coverage (pooled RR across 19 studies: 1.42 [95% CI 1.16–1.75], p = 0.002), time until ART initiation (pooled RR across 5 studies: 0.45 [95% CI 0.20–1.00], p = 0.050), retention in HIV care (pooled RR across 19 studies: 1.68 [95% CI 1.05–2.69], p = 0.031), and viral suppression (pooled RR across 9 studies: 1.19 [95% CI 1.03–1.37], p = 0.025). Also, treatment success for non-HIV-related diseases and conditions and the uptake of non-HIV services were commonly higher in integrated services. We did not find any significant differences for the following outcomes in our meta-analyses: HIV testing yield, ART adherence, HIV-free survival among infants, and HIV and non-HIV mortality. We could not conduct meta-analyses for several outcomes (HIV infections averted, costs, and cost-effectiveness), because our systematic review did not identify sufficient poolable studies. Study limitations included possible publication bias of studies with significant or favourable findings and comparatively weak evidence from some world regions and on integration of services for key populations in the HIV response. Conclusions Integration of HIV services and other health services tends to improve health and health systems outcomes. Despite some scientific limitations, the global evidence shows that service integration can be a valuable strategy to boost the sustainability of the HIV response and contribute to the goal of ‘ending AIDS by 2030’, while simultaneously supporting progress towards universal health coverage.

Hypertension care cascade at a large urban HIV clinic in Uganda: a mixed methods study using the Capability, Opportunity, Motivation for Behavior change (COM-B) model

Background Persons living with HIV (PLHIV) receiving antiretroviral therapy (ART) have a high prevalence of hypertension (HTN) and increased risk of mortality from cardiovascular diseases. HTN and HIV care integration is recommended in Uganda, though its implementation has lagged. In this study, we sought to analyze the HTN and HIV care cascades and explore barriers and facilitators of HTN/HIV integration within a large HIV clinic in urban Uganda. Methods We conducted an explanatory sequential mixed methods study at Mulago ISS clinic in Kampala, Uganda. We determined proportions of patients in HTN and HIV care cascade steps of screened, diagnosed, initiated on treatment, retained, and controlled. Guided by the Capability, Opportunity, Motivation and Behavior (COM-B) model, we then conducted semi-structured interviews and focus group discussions with healthcare providers (n = 13) and hypertensive PLHIV (n = 32). We coded the qualitative data deductively and analyzed the data thematically categorizing them as themes that influenced HTN care positively or negatively. These denoted barriers and facilitators, respectively. Results Of 15,953 adult PLHIV, 99.1% were initiated on ART, 89.5% were retained in care, and 98.0% achieved control (viral suppression) at 1 year. All 15,953 (100%) participants were screened for HTN, of whom 24.3% had HTN. HTN treatment initiation, 1-year retention, and control were low at 1.0%, 15.4%, and 5.0%, respectively. Barriers and facilitators of HTN/HIV integration appeared in all three COM-B domains. Barriers included low patient knowledge of HTN complications, less priority by patients for HTN treatment compared to ART, sub-optimal provider knowledge of HTN treatment, lack of HTN treatment protocols, inadequate supply of anti-hypertensive medicines, and lack of HTN care performance targets. Facilitators included patients’ and providers’ interest in HTN/HIV integration, patients’ interest in PLHIV peer support, providers’ knowledge and skills for HTN screening, optimal ART adherence counseling, and availability of automated BP machines. Conclusion The prevalence of HTN among PLHIV is high, but the HTN care cascade is sub-optimal in this successful HIV clinic. To close these gaps, models of integrated HTN/HIV care are urgently needed. These findings provide a basis for designing contextually appropriate interventions for HTN/HIV integration in Uganda and other low- and middle-income countries.

A practical clinical guide to counselling on and managing contraception, pre-conception planning, and menopause for women living with HIV

Background: Women represent one quarter of the population living with HIV in Canada and are an increasingly important sector of the HIV community. While some women’s health issues such as cervical cancer screening and management are well addressed in HIV management guidelines, others are not. These include sexual and reproductive health factors such as contraception, pre-conception planning, and menopause. Existing literature has shown that while women living with HIV in Canada receive good HIV care based on HIV care cascade indicators, their women’s health and sexual and reproductive health care needs are not being met. Methods: In this article, we present a clinical guide for clinicians providing care for women living with HIV on three key women’s health topics that are under-discussed during HIV care visits: (1) contraception, (2) pre-conception planning, and (3) menopause. Results: We have summarized the most pertinent clinical factors on each topic to support straightforward counselling and present important considerations in the context of HIV-related diseases and treatment. Finally, when relevant, we have provided practical stepwise approaches for addressing each of these women’s health care topics when seeing a patient during a visit. Conclusions: It is important that HIV specialists stay well-versed in the complex clinical interactions between HIV treatment and management of women’s health issues.

Impact of Traditional Healers on the HIV Care Cascade in Senegal, West Africa: A Longitudinal Study

Consultation with traditional healers (THs) is common among people living with HIV in sub-Saharan Africa. We conducted a prospective longitudinal study to determine the association between consultation with THs and HIV outcomes following 12 months of antiretroviral therapy (ART). HIV-infected individuals presenting for care and initiation of ART in Dakar and Ziguinchor, Senegal were eligible for enrollment. Data were collected using interviews, clinical evaluations, laboratory analyses, and chart reviews at enrollment, 6 months after ART initiation, and 12 months after ART initiation. Among the 186 participants, 35.5% consulted a TH. The most common reason for consulting a TH was “mystical” concerns (18%). Those who consulted a TH before ART initiation were more likely to present with a CD4 count < 200 cells/mm3 (44% versus 28%; P = 0.04) and WHO stage 3 or 4 disease (64% versus 46%; P = 0.03), and they were less likely to disclose their HIV status (44% versus 65%; P = 0.04). Those who consulted a TH more than 6 months after ART initiation were more likely to report poor adherence to ART (57% versus 4%; P < 0.01). The strongest predictor of virologic failure was consulting a TH more than 6 months after ART initiation (odd ratio [OR], 7.43; 95% CI, 1.22–45.24). The strongest predictors of mortality were consulting a TH before ART initiation (OR, 3.53; 95% CI, 1.25–9.94) and baseline CD4 count < 200 cells/mm3 (OR, 3.15; 95% CI, 1.12–8.89). Our findings reveal multiple opportunities to strengthen the HIV care cascade through partnerships between THs and biomedical providers. Future studies to evaluate the impact of these strategies on HIV outcomes are warranted.

Engaging the ‘Missing Men’ in the HIV Treatment Cascade: Creating a Tailored Intervention to Improve Men’s Uptake of HIV Care Services in Rural South Africa: A Study Protocol

Men, especially young men, have been consistently missing from the HIV care cascade, leading to poor health outcomes in men and ongoing transmission of HIV in young women in South Africa. Although these men may not be missing for the same reasons across the cascade and may need different interventions, early work has shown similar trends in men’s low uptake of HIV care services and suggested that the social costs of testing and accessing care are extremely high for men, particularly in South Africa. Interventions and data collection have hitherto, by and large, focused on men in relation to HIV prevention in women and have not approached the problem through the male lens. Using the participatory method, the overall aim of this study is to improve health outcomes in men and women through formative work to co-create male-specific interventions in an HIV-hyper endemic setting in rural KwaZulu-Natal, South Africa.