scholarly journals Preparing a Financial Incentive Program to Improve Adherence to ART for Scale: Using an Implementation Science Framework to Evaluate an mHealth System in Tanzania

2021 ◽  
Author(s):  
Laura Packel ◽  
Carolyn Fahey ◽  
Atuganile Kalinjila ◽  
Agatha Mnyippembe ◽  
Prosper Njau ◽  
...  
Keyword(s):  
Implementation Science ◽  
Financial Incentives ◽  
Viral Suppression ◽  
Cash Transfers ◽  
Sub Saharan Africa ◽  
Biometric Identification ◽  
People Living With Hiv ◽  
Main Trial ◽  
Mobile Money ◽  
Mobile Payments

Abstract Background: Viral suppression is key to ending the HIV epidemic, yet only 58% of people living with HIV (PLHIV) in sub-Saharan Africa are suppressed. Cash transfers are an effective strategy to improve adherence, but little is known about optimization of implementation; for example, designing effective programs that integrate into existing clinic workflows. We studied implementation of an mHealth system to deliver cash transfers to support antiretroviral medication (ART) adherence.Methods: We conducted an “implementation science-effectiveness” randomized controlled trial evaluating cash transfers conditional on visit attendance for viral suppression among Tanzanian PLHIV initiating ART. An mHealth system using fingerprint identification and mobile payments was used to automatically disburse mobile money to eligible PLHIV. We used Proctor’s framework, assessing implementation of the mHealth system from the perspectives of PLHIV and clinicians. We analyzed mHealth system data and conducted surveys (n=530) and in-depth interviews (n=25) with PLHIV, clinic and pharmacy staff (n=10), and structured clinic observations (n=2,293 visits).Results: 1,651 cash transfers were delivered to 346 PLHIV in the cash arms, 78% through mobile money. Among those in the cash arms, 81% registered their mobile money account with the mHealth system by study end, signaling high adoption. While acceptability for fingerprinting and mobile payments was high among PLHIV, interviews revealed mixed views: some had privacy concerns while others felt the system was secure and accurate, and provided some legitimacy to the clinical visits. Pharmacists praised system efficiency, but concerns about duplicative recordkeeping and added work arose. Clinic staff voiced excitement for the system’s potential to bring the cash program to all patients and simplify workflows; yet concerns about multiple systems, staffing, and intermittent connectivity tempered enthusiasm, highlighting structural issues beyond program scope. Structured observations revealed a steep learning curve; repeat fingerprint scans and manual entry declined as the system improved. Conclusions: Biometric identification and mobile payments were acceptable to most patients and staff. Fingerprinting encountered some feasibility limitations in the first months of testing, however mobile payments were highly successful. Biometric identification and mobile payments may provide a scalable mechanism to improve patient tracking and efficiently implement financial incentives in low-resource settings.Trial RegistrationName of the registry: clinicaltrials.govTrial registration number: NCT03351556Date of registration: 11/24/2017URL of trial registry record: https://clinicaltrials.gov/ct2/show/NCT03351556?term=mccoy&cntry=TZ&draw=2&rank=4Checklists: StaRI (included with submission). Note CONSORT for cluster randomized trials was used for the main trial but is not directly applicable to this manuscript.

scholarly journals Preparing a financial incentive program to improve retention in HIV care and viral suppression for scale: using an implementation science framework to evaluate an mHealth system in Tanzania

2021 ◽  
Vol 2 (1) ◽  
Author(s):  
Laura Packel ◽  
Carolyn Fahey ◽  
Atuganile Kalinjila ◽  
Agatha Mnyippembe ◽  
Prosper Njau ◽  
...  
Keyword(s):  
Viral Suppression ◽  
Cash Transfers ◽  
Sub Saharan Africa ◽  
Trial Registration ◽  
Hiv Care ◽  
Biometric Identification ◽  
People Living With Hiv ◽  
Main Trial ◽  
Mobile Money ◽  
Mobile Payments

Abstract Background Viral suppression is key to ending the HIV epidemic, yet only 58% of people living with HIV (PLHIV) in sub-Saharan Africa are suppressed. Cash transfers are an effective strategy to improve retention in care, but little is known about optimization of implementation; for example, designing effective programs that integrate into existing clinic workflows. We studied implementation of an mHealth system to deliver cash transfers to support retention. Methods We conducted a mixed-methods study assessing implementation of an mHealth cash transfer study. This was part of a larger, hybrid implementation-effectiveness randomized controlled trial evaluating cash transfers conditional on visit attendance for viral suppression among Tanzanian PLHIV initiating ART. An mHealth system using fingerprint identification and mobile payments was used to automatically disburse mobile money to eligible PLHIV. We used Proctor’s framework, assessing implementation of the mHealth system from the perspectives of PLHIV and clinicians. We analyzed mHealth system data and conducted surveys (n = 530) and in-depth interviews (n = 25) with PLHIV, clinic and pharmacy staff (n = 10), and structured clinic observations (n = 2293 visits). Results One thousand six hundred fifty-one cash transfers were delivered to 346 PLHIV in the cash arms, 78% through mobile money. Among those in the cash arms, 81% registered their mobile money account with the mHealth system by study end, signaling high adoption. While acceptability for fingerprinting and mobile payments was high among PLHIV, interviews revealed mixed views: some had privacy concerns while others felt the system was secure and accurate, and provided some legitimacy to the clinical visits. Pharmacists praised system efficiency, but concerns about duplicative recordkeeping and added work arose. Clinic staff voiced excitement for the system’s potential to bring the cash program to all patients and simplify workflows; yet concerns about multiple systems, staffing, and intermittent connectivity tempered enthusiasm, highlighting structural issues beyond program scope. Structured observations revealed a steep learning curve; repeat fingerprint scans and manual entry declined as the system improved. Conclusions Biometric identification and mobile payments were acceptable to most patients and staff. Fingerprinting encountered some feasibility limitations in the first months of testing; however, mobile payments were highly successful. Biometric identification and mobile payments may provide a scalable mechanism to improve patient tracking and efficiently implement financial incentives in low-resource settings. Trial registration Name of the registry: clinicaltrials.gov Trial registration number: NCT03351556 Date of registration: 11/24/2017 Checklists: StaRI (included with submission). Note CONSORT for cluster-randomized trials was used for the main trial but is not directly applicable to this manuscript.

Human immunodeficiency virus funding and access to treatment in sub-Saharan Africa

2021 ◽  
pp. 095646242110422
Author(s):  
Reuben Granich ◽  
Somya Gupta ◽  
Brian Williams
Keyword(s):  
Human Immunodeficiency Virus ◽  
Viral Suppression ◽  
Hiv Treatment ◽  
Sub Saharan Africa ◽  
People Living With Hiv ◽  
Access To Treatment ◽  
Immunodeficiency Virus ◽  
Sub Saharan ◽  
Living With Hiv ◽  
Hiv Funding

Human immunodeficiency virus (HIV) treatment prevents illness, death, and transmission. The 90-90-90 disease control target is only 73% of people living with HIV virally suppressed. For 2010 to 2019, we abstracted HIV funding data for 40 countries in sub-Saharan Africa (70% of global HIV burden and >99% of HIV burden in the region in 2018). During 2010–2019, there was ∼$52 billion funding for 40 countries (99% Africa HIV burden). Domestic funding ranged from $0 to $3.2 billion. PEPFAR funding was $32 billion (average $1.4 billion; range $0.089–4.3 billion) among 22 countries. Global Fund averaged $306 million ($1.9 million to $1.1 billion) for 40 countries. Among PLHIV, known HIV status averaged 80% (11% to 94%). ART coverage averaged 64% (9% to 90%). Viral suppression among PLHIV ranged from 8% to 87%. Of the 40 countries, 21 reported under 60% of PLHIV to be on treatment and 13 did not report viral suppression for 2018. Achieving 90-90-90 is feasible in challenging settings if resources are used efficiently. Despite the significant investment in the HIV response, many countries have not reached the 90-90-90 target. Greater attention to efficiency and prioritizing important targets will be required to end AIDS in Africa.

scholarly journals Mixed method estimation of population level HIV viral suppression rate in the Western Cape, South Africa

2020 ◽  
Author(s):  
Elton Mukonda ◽  
Nei-Yuan Hsiao ◽  
Lara Vojnov ◽  
Landon Myer ◽  
Maia Lesosky
Keyword(s):  
Viral Suppression ◽  
Routine Data ◽  
Population Level ◽  
Hiv Prevalence ◽  
Sub Saharan Africa ◽  
Sensitivity Analyses ◽  
People Living With Hiv ◽  
Western Cape ◽  
Test Results ◽  
Individual Level

AbstractIntroductionThere are few population-wide data on viral suppression (VS) that can be used to monitor programmatic targets in sub-Saharan Africa. We describe how routinely collected viral load (VL) data from ART programmes can be extrapolated to estimate population VS and validate this using a combination of empiric and model-based estimates.MethodsVL test results from were matched using a record linkage algorithm to obtain linked results for individuals. Test- and individual-level VS rates were based on test VL values <1000 cps/ml, and individual VL <1000 cps/mL in a calendar year, respectively. We calculated population VS among people living with HIV (PLWH) in the province by combining census-derived mid-year population estimates, HIV prevalence estimates and individual level VS estimates from routine VL data.ResultsApproximately 1.9 million VL test results between 2008 – 2018 were analysed. Among individuals in care, VS increased from 85.5% in 2008 to 90% in 2018. Population VS among all PLWH in the province increased from 12.2% in 2008 to 51.0% in 2017. The estimates derived from this method are comparable to those from other published studies. Sensitivity analyses showed that the results are robust to variations in linkage method, but sensitive to the extreme combinations of assumed ART coverage and population HIV prevalence.ConclusionWhile validation of this method in other settings is required, this approach provides a simple, robust method for estimating population VS using routine data from ART services that can be employed by national programmes in high-burden settings.

scholarly journals Mixed-method estimation of population-level HIV viral suppression rate in the Western Cape, South Africa

2020 ◽  
Vol 5 (8) ◽  
pp. e002522
Author(s):  
Elton Mukonda ◽  
Nei-Yuan Hsiao ◽  
Lara Vojnov ◽  
Landon Myer ◽  
Maia Lesosky
Keyword(s):  
Viral Suppression ◽  
Routine Data ◽  
Population Level ◽  
Hiv Prevalence ◽  
Sub Saharan Africa ◽  
Sensitivity Analyses ◽  
People Living With Hiv ◽  
Western Cape ◽  
Test Results ◽  
Individual Level

IntroductionThere are few population-wide data on viral suppression (VS) that can be used to monitor programmatic targets in sub-Saharan Africa. We describe how routinely collected viral load (VL) data from antiretroviral therapy (ART) programmes can be extrapolated to estimate population VS and validate this using a combination of empiric and model-based estimates.MethodsVL test results from were matched using a record linkage algorithm to obtain linked results for individuals. Test-level and individual-level VS rates were based on test VL values <1000 cps/mL, and individual VL <1000 cps/mL in a calendar year, respectively. We calculated population VS among people living with HIV (PLWH) in the province by combining census-derived midyear population estimates, HIV prevalence estimates and individual level VS estimates from routine VL data.ResultsApproximately 1.9 million VL test results between 2008 and 2018 were analysed. Among individuals in care, VS increased from 85.5% in 2008 to 90% in 2018. Population VS among all PLWH in the province increased from 12.2% in 2008 to 51.0% in 2017. The estimates derived from this method are comparable to those from other published studies. Sensitivity analyses showed that the results are robust to variations in linkage method, but sensitive to the extreme combinations of assumed VL testing coverage and population HIV prevalence.ConclusionWhile validation of this method in other settings is required, this approach provides a simple, robust method for estimating population VS using routine data from ART services that can be employed by national programmes in high-burden settings.

scholarly journals A systematic review of the effectiveness of non- health facility based care delivery of antiretroviral therapy for people living with HIV in sub-Saharan Africa measured by viral suppression, mortality and retention on ART

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Mohammed Limbada ◽  
Geiske Zijlstra ◽  
David Macleod ◽  
Helen Ayles ◽  
Sarah Fidler
Keyword(s):  
Health Facility ◽  
Viral Suppression ◽  
Risk Difference ◽  
Hazard Ratio ◽  
Sub Saharan Africa ◽  
People Living With Hiv ◽  
Viral Load Suppression ◽  
Loss To Follow Up ◽  
Sub Saharan ◽  
Art Delivery

Abstract Background Alternative models for sustainable antiretroviral treatment (ART) delivery are necessary to meet the increasing demand to maintain population-wide ART for all people living with HIV (PLHIV) in sub-Saharan Africa. We undertook a review of published literature comparing health facility-based care (HFBC) with non-health facility based care (nHFBC) models of ART delivery in terms of health outcomes; viral suppression, loss to follow-up, retention and mortality. Methods We conducted a systematic search of Medline, Embase and Global Health databases from 2010 onwards. UNAIDS reports, WHO guidelines and abstracts from conferences were reviewed. All studies measuring at least one of the following outcomes, viral load suppression, loss-to-follow-up (LTFU) and mortality were included. Data were extracted, and a descriptive analysis was performed. Risk of bias assessment was done for all studies. Pooled estimates of the risk difference (for viral suppression) and hazard ratio (for mortality) were made using random-effects meta-analysis. Results Of 3082 non-duplicate records, 193 were eligible for full text screening of which 21 published papers met the criteria for inclusion. The pooled risk difference of viral load suppression amongst 4 RCTs showed no evidence of a difference in viral suppression (VS) between nHFBC and HFBC with an overall estimated risk difference of 1% [95% CI -1, 4%]. The pooled hazard ratio of mortality amongst 2 RCTs and 4 observational cohort studies showed no evidence of a difference in mortality between nHFBC and HFBC with an overall estimated hazard ratio of 1.01 [95% CI 0.88, 1.16]. Fifteen studies contained data on LTFU and 13 studies on retention. Although no formal quantitative analysis was performed on these outcomes due to the very different definitions between papers, it was observed that the outcomes appeared similar between HFBC and nHFBC. Conclusions Review of current literature demonstrates comparable outcomes for nHFBC compared to HFBC ART delivery programmes in terms of viral suppression, retention and mortality. PROSPERO number CRD42018088194.

scholarly journals The CombinADO study to assess the impact of a combination intervention strategy on viral suppression, antiretroviral therapy adherence, and retention in HIV care among adolescents and young people living with HIV: protocol for a cluster-randomized controlled trial

Trials ◽  
2021 ◽  
Vol 22 (1) ◽  
Author(s):  
Phepo Mogoba ◽  
Maia Lesosky ◽  
Allison Zerbe ◽  
Joana Falcao ◽  
Claude Ann Mellins ◽  
...  
Keyword(s):  
Mental Health ◽  
Support Groups ◽  
Viral Suppression ◽  
Sub Saharan Africa ◽  
Hiv Care ◽  
People Living With Hiv ◽  
Retention In Hiv Care ◽  
Cluster Randomized ◽  
Living With Hiv ◽  
The Impact

Abstract Background Adolescents and youth living with HIV (AYAHIV) have worse HIV outcomes than other age groups, particularly in sub-Saharan Africa (SSA). AYAHIV in SSA face formidable health system, interpersonal- and individual-level barriers to retention in HIV care, uptake of ART, and achievement of viral suppression (VS), underscoring an urgent need for multi-component interventions to address these challenges. This cluster-randomized control trial (cRCT) aims to evaluate the effectiveness and monitor implementation of a community-informed multi-component intervention (“CombinADO strategy”) addressing individual-, facility-, and community-level factors to improve health outcomes for AYAHIV. Methods This trial will be conducted in 12 clinics in Nampula Province, Northern Mozambique. All clinics will implement an optimized standard of care (control) including (1) billboards/posters and radio shows, (2) healthcare worker (HCW) training, (3) one-stop adolescent and youth-friendly services, (4) information/motivation walls, (5) pill containers, and (6) tools to be used by HCW during clinical visits. The CombinADO strategy (intervention) will be superadded to control conditions at 6 randomly selected clinics. It will include five additional components: (1) peer support, (2) informational/motivational video, (3) support groups for AYAHIV caregivers, (4) AYAHIV support groups, and (5) mental health screening and linkage to adolescent-focused mental health support. The study conditions will be in place for 12 months; all AYAHIV (ages 10–24 years, on ART) seeking care in the participating sites will be exposed to either the control or intervention condition based on the clinic they attend. The primary outcome is VS (viral load < 50 copies/mL) at 12 months among AYAHIV attending participating clinics. Secondary outcomes include ART adherence (self-reported and TDF levels) and retention in care (engagement in the preceding 90 days). Uptake, feasibility, acceptability, and fidelity of the CombinADO strategy during implementation will be measured. Trial outcomes will be assessed in AYAHIV, caregivers, healthcare workers, and key informants. Statistical analyses will be conducted and reported in line with CONSORT guidelines for cRCTs. Discussion The CombinADO study will provide evidence on effectiveness and inform implementation of a novel community-informed multi-component intervention to improve retention, adherence, and VS among AYAHIV. If found effective, results will strengthen the rationale for scale up in SSA. Trial registration ClinicalTrials.gov NCT04930367. Registered on 18 June 2021

scholarly journals Pandemics and Burden of Stroke and Epilepsy in Sub-Saharan Africa: Experience from a Longstanding Health Programme

2021 ◽  
Vol 18 (5) ◽  
pp. 2766
Author(s):  
Massimo Leone ◽  
Fausto Ciccacci ◽  
Stefano Orlando ◽  
Sandro Petrolati ◽  
Giovanni Guidotti ◽  
...  
Keyword(s):  
Neurological Disorders ◽  
Combined Treatment ◽  
Cerebrovascular Disorders ◽  
Sub Saharan Africa ◽  
Noncommunicable Diseases ◽  
People Living With Hiv ◽  
Sub Saharan ◽  
Health Programme ◽  
Excess Deaths ◽  
Hiv Aids

Eighty percent of people with stroke live in low- to middle-income nations, particularly in sub-Saharan Africa (SSA) where stroke has increased by more than 100% in the last decades. More than one-third of all epilepsy−related deaths occur in SSA. HIV infection is a risk factor for neurological disorders, including stroke and epilepsy. The vast majority of the 38 million people living with HIV/AIDS are in SSA, and the burden of neurological disorders in SSA parallels that of HIV/AIDS. Local healthcare systems are weak. Many standalone HIV health centres have become a platform with combined treatment for both HIV and noncommunicable diseases (NCDs), as advised by the United Nations. The COVID-19 pandemic is overwhelming the fragile health systems in SSA, and it is feared it will provoke an upsurge of excess deaths due to the disruption of care for chronic diseases such as HIV, TB, hypertension, diabetes, and cerebrovascular disorders. Disease Relief through Excellent and Advanced Means (DREAM) is a health programme active since 2002 to prevent and treat HIV/AIDS and related disorders in 10 SSA countries. DREAM is scaling up management of NCDs, including neurologic disorders such as stroke and epilepsy. We described challenges and solutions to address disruption and excess deaths from these diseases during the ongoing COVID-19 pandemic.

scholarly journals Antiretroviral Drugs Impact Autophagy with Toxic Outcomes

Cells ◽  
2021 ◽  
Vol 10 (4) ◽  
pp. 909
Author(s):  
Laura Cheney ◽  
John M. Barbaro ◽  
Joan W. Berman
Keyword(s):  
Quality Control ◽  
Antiretroviral Therapy ◽  
Side Effects ◽  
Viral Suppression ◽  
Antiretroviral Drugs ◽  
People Living With Hiv ◽  
Foreign Material ◽  
Complete Understanding ◽  
Living With Hiv ◽  
Target Effects

Antiretroviral drugs have dramatically improved the morbidity and mortality of people living with HIV (PLWH). While current antiretroviral therapy (ART) regimens are generally well-tolerated, risks for side effects and toxicity remain as PLWH must take life-long medications. Antiretroviral drugs impact autophagy, an intracellular proteolytic process that eliminates debris and foreign material, provides nutrients for metabolism, and performs quality control to maintain cell homeostasis. Toxicity and adverse events associated with antiretrovirals may be due, in part, to their impacts on autophagy. A more complete understanding of the effects on autophagy is essential for developing antiretroviral drugs with decreased off target effects, meaning those unrelated to viral suppression, to minimize toxicity for PLWH. This review summarizes the findings and highlights the gaps in our knowledge of the impacts of antiretroviral drugs on autophagy.

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