A sub-group evaluation of the multi-month dispensing strategy for differentiated HIV care: is personalization of care guidelines warranted in Haiti?

Background Differentiated care strategies are rapidly becoming the norm for HIV care delivery globally. Building upon an interest in tailoring antiretroviral therapy (ART) delivery for client-centered needs, the Ministry of Health and Population in Haiti formally endorsed multiple-month dispenses (MMD) in the 2016 national ART guidelines This study explores heterogeneity in retention in care with MMD for specific Haitian populations living with HIV and evaluates if a targeted algorithm for optimal ART prescription intervals is warranted in Haiti. Methods This study included ART-naïve individuals who started ART on or after January 1st, 2017 in Haiti. To identify subgroups in which to explore heterogeneity of retention, we implemented a double-lasso regression method to determine which individual characteristics would define the subgroups. Characteristics evaluated for potential subgroup definition included: sex, age category, WHO clinical stage, and body mass index category. We employed instrumental variable models to estimate the causal effect of increasing ART dispensing length on ART retention, by client subgroup. The outcome of interest was retention in care after one year in treatment. We then estimated the marginal effect of a 30-day increase to ART dispensing length to retention in care for each of these subgroups. Results There was evidence for heterogeneity in the effect of extending ART dispensing intervals on retention by WHO clinical stage. We observed significant improvements to retention in care at one year with a 30-day increase in ART dispense length for all subgroups defined by WHO clinical stages 1-4. The effects ranged from a 14.7% increase (95% CI: 12.4-17.0) to the likelihood of retention for people with HIV in WHO stage 1 to a 21.6% increase (95% CI: 18.7-24.5) to the likelihood of retention for those in WHO stage 3. Conclusions All the subgroups defined by WHO clinical stage experienced a benefit of extending ART intervals to retention in care at one year. Though the effect did differ slightly by WHO stage, the effects went in the same direction and were of similar magnitude. Therefore, a standardized recommendation for MMD among those living with HIV and new on ART is appropriate for Haiti treatment guidelines.

A Technology-Based Intervention Among Young Men Who Have Sex With Men and Nonbinary People (The Conectad@s Project): Protocol for A Vanguard Mixed Methods Study

Background In many parts of the world, including Brazil, uptake for biomedical interventions has been insufficient to reverse the HIV epidemic among key populations at high risk for HIV, including men who have sex with men. Young MSM (YMSM), particularly Black YMSM, have high HIV incidence, low viral suppression, and low preexposure prophylaxis (PrEP) uptake and adherence. Therefore, novel approaches to increase the HIV biomedical interventions uptake by YMSM are urgently needed. Objective We describe the Conectad@s Project, which aims to: (1) estimate the prevalence and incidence of HIV and other sexually transmitted infections, the onset of sexual risk behavior, and barriers to biomedical interventions among YMSM aged 18 to 24 years in Rio de Janeiro, Brazil; and (2) conduct a technology-based adherence intervention study to promote a rapid linkage of YMSM to HIV care or prevention, and support and sustain adherence. Methods A cross-sectional survey will be conducted with 400 YMSM recruited using respondent-driven sampling (RDS) adapted for social media-based sampling, preceded by a formative phase. HIV and sexually transmitted infections testing will be conducted, including early HIV infection biomarker detection. Behavioral, partnership, network, and structural measures will be collected through structured questionnaires. All individuals recruited for the survey will have access to HIV risk assessment, antiretroviral therapy (ART), PrEP, prevention counseling, and a technology-based adherence intervention. Those who accept the adherence intervention will receive weekly text messages via a social networking app (WhatsApp) for 24 weeks, with follow-up data collected over 48 weeks. Results The Conectad@s project has been approved by our local institutional review board (#CAAE 26086719.0.0000.4262) in accordance with all applicable regulations. Questionnaires for the RDS survey and intervention were developed and tested in 2020, formative interviews were conducted in January and February 2021 to guide the development of the RDS, and enrollment is planned to begin in early 2022. Conclusions The Conectad@s Project is a vanguard study that, for the first time, will apply digital RDS to sample and recruit YMSM in Brazil and rapidly connect them to ART, PrEP, or prevention counseling through a technology-based adherence intervention. RDS will allow us to estimate HIV prevalence among YMSM and measure HIV infection biomarkers in the context of the onset of risky behavior. The data will lay the groundwork to adapt and implement HIV prevention strategies, identify barriers to the earliest HIV infection diagnosis, immediate ART or PrEP initiation, and detect new clusters of HIV transmission. International Registered Report Identifier (IRRID) DERR1-10.2196/34885

Incidence and predictors of anemia among adults on HIV care at South Gondar Zone Public General Hospital Northwest Ethiopia, 2020; retrospective cohort study

Background Anemia is a major public health problem worldwide which accounts 24.8% of the population. Subsequently, anemia is a leading killer of people living with human immunodeficiency virus and many of these deaths occur in developing countries including Ethiopia. Cross sectional studies have done on anemia and human immunodeficiency virus. However, there is limited study on incidence of anemia and its predictors among adults on HIV care, especially no survival study has been conducted in the study area. Objective To assess incidence and predictors of anemia among adults on Human immunodeficiency virus care. Methods An institution-based retrospective cohort study was conducted among 434 adults on HIV care from January 1st 2015 to December 30th 2019 at Debre Tabor Referral Hospital. A computer-generated simple random sampling technique was employed to select the study participants. Ethical clearance was obtained from the Institutional Review Board of Bahir Dar University, and also, we got implied consent to review charts from the concerned bodies in the hospital. Data were entered using Epi-data version 3.1 and analyzed by using STATA version 14.0. A Kaplan Meier survival curve was utilized to estimate anemia free survival time. Bivariable and Multivariable Cox proportional hazards model were fitted to identify predictors of anemia. Results The overall incidence density rate of anemia was 6.27 (95% CI: 0.051, 0.077) per 100 person years. Clinical stage III/IV (AHR = 1.04; 95% CI = 1.02, 1.06), Body Mass Index less than 18.5 kg/m2 (AHR = 3.11; 95% CI = 1.56, 6.22), serum creatinine greater than 1.1 IU/L(AHR = 2.07; 95% CI = 1.12, 3.81) and fair/poor level of adherence(AHR = 1.05; 95% CI = 1.03, 1.07) were statistically significant predictors of anemia while increased anti-retroviral treatment duration (AHR = 0.98; 95% CI = 0.97, 0.99) decrease the risk of anemia at 95% confidence level. Conclusion The overall incidence density rate of anemia was high. Patients with clinical stage III/IV, body mass index < 18.5 kg/m2, serum creatinine greater than 1.1 IU/L and fair/poor level of adherence were significant predictors of anemia while increased antiretroviral treatment duration had decreased the risk of anemia. Recommendation Even if the overall incidence rate of anemia was lower as compared to previous studies in Ethiopia, still the incidence of anemia was high. So, prevention measures should be taken beside with HIV care especially within 6-months ART initiation.

Exploring peer navigation and support in the quality of HIV care experiences of female sex workers in the Dominican Republic

Background Despite evidence on peer navigation’s association with positive HIV outcomes, such as engagement in HIV care and antiretroviral therapy (ART) initiation, the mechanisms through which peer navigation may influence these outcomes have been less explored. The purpose of this study is to describe the role of peer navigation and support on enhancing the quality of HIV treatment and care services experienced by female sex workers (FSWs). Methods Survey data was derived from a quantitative cohort (n = 211) of FSWs living with HIV in the Dominican Republic and complemented with data from two rounds of in-depth interviews (IDIs) from a qualitative subsample (n = 20 per round). Descriptive statistics and multivariable logistic regressions were used to explore the association between peer navigation and relational aspects of care and overall satisfaction of the quality of HIV treatment and care. Thematic analysis was employed to code and synthesize textual data from IDIs. Results 41.2% of the participants reported having had contact with a peer navigator in the last 6 months. Qualitative data revealed that peer navigation and support was instrumental in assisting FSWs linkage to HIV care after diagnosis, elevating FSWs’ ability to access more comprehensive clinical care facilities, and promoting agency by improving FSWs’ skills to more strategically and effectively engage with the clinic environment and health care providers. Peer navigation was positively associated with experiencing more respectful treatment by clinic staff (AOR: 6.65, 95% CI: 2.32–19.02), and greater satisfaction with overall HIV care services (AOR: 2.57, 95% CI: 1.77–3.74). Conclusion Promoting the full integration of peer navigation into healthcare structures is a strategic approach to enhance the quality of HIV care experienced by FSWs and improve their HIV-related outcomes.

Developing a Consensus for Adolescent and Young Adult mHealth HIV Prevention Interventions in the United States: Delphi Method (Preprint)

BACKGROUND Engaging adolescents and young adults (AYA) who are at elevated risk for HIV acquisition or who are living with HIV in healthcare has posed a major challenge in HIV prevention and care efforts. Mobile health (mHealth) interventions are a popular and accessible strategy to support AYA engagement despite barriers to care present along the HIV care continuum. Even with progress in the field of mHealth research, expert recommendations for the process of designing, evaluating, and implementing HIV-related mHealth interventions are underdeveloped. OBJECTIVE The aim of this study was to compile expert recommendations on the development, evaluation, and implementation of AYA-focused HIV prevention and care mHealth interventions. METHODS Experts from adolescent mHealth HIV research networks and investigators of recently funded HIV mHealth projects and programs were identified and invited to complete a series of electronic surveys related to the design, implementation, and evaluation of HIV-related mHealth interventions. A modified Delphi method was used to ask experts to score 35 survey items on a 4-point Likert scale from not important to very important and encouraged experts to leave additional comments in text boxes. Responses were reviewed by the researchers, a team of four HIV mHealth intervention experts. The average importance ratings from survey responses were calculated and then categorized as retained (high importance), flagged (mid-level importance), or dropped (no/low importance). Additionally, thematic analysis of expert comments helped modify survey items for the next survey round. An evaluation of the level of agreement among experts on the most important items followed each round until consensus was reached. RESULTS Of the 35 invited experts, 23 completed the first survey representing a variety of roles within a research team. Following two rounds of Delphi surveys, experts scored 86% of the 30 survey items included in round two as important to very important. The final consensus items included 24 recommendations related to the mHealth intervention design process (n=15), evaluation (n=2), and implementation (n=7). The three survey items with the highest average scores focused on the design process, specifically, (1) creating a diverse team including researchers, app software developers, youth representation, (2) the importance of AYA-focused content, and the (3) value of an iterative process. Additionally, experts highlighted the importance of establishing the best ways to collect data and the types of data for collection during the evaluation process as well as constructing a plan for participant technology disruption when implementing an mHealth intervention. CONCLUSIONS The modified Delphi method was a useful tool to convene experts to determine recommendations for AYA-focused HIV prevention and care mHealth interventions. These recommendations can inform future mHealth interventions. To ensure acceptability, feasibility, and efficacy of these AYA HIV prevention interventions, the focus must be on specific needs of AYA by including representation of AYA in the process, including consistent and relevant content, ensuring appropriate data is collected, and considering technology and health accessibility barriers.

Prevalence of Overweight And Obesity And Associated Factors Among People Living With Hiv Attending A Tertiary Care Clinic In Uganda

Background: Overweight and obesity are significantly increasing among people living with HIV (PLWH), contributing to the risk of major adverse cardio-metabolic events. However, little is known on its prevalence among PLWH in sub-Saharan Africa. In this study, we report the prevalence and factors associated with overweight and obesity among PLWH in a large tertiary HIV clinic in Kampala, Uganda. Methods: A cross-sectional, retrospective review of electronic database of all PLWH that attended the Adult Infectious Diseases Institute clinic between November 2018 and April 2019 was conducted. Demographic, body mass index (BMI) [kg/m2] and clinical variables were extracted. Based on BMI, nutritional status was classified as undernutrition (< 18.5kg/m2), normal (≥18.5 < 25kg/m2), overweight (≥25 < 30kg/m2) and obesity (≥ 30kg/m2). Poisson regression analysis was performed to determine factors associated with overweight and obesity.Results: Overall, 7,818 participants were included in the analysis, 64% (n=4,976) were female, with a median age of 44 years (interquartile range (IQR): 36 — 51) and a median BMI of 24.2 (IQR: 21.2 — 28.1). The prevalence of overweight and obesity combined was 46% (55% female versus 30% male), obesity 18.2% (24.6% female versus 7.1% male) and overweight 27.8% (30.4% female versus 22.9% male). Factors associated with overweight and obesity were: Female sex (adjusted prevalence ratio [aPR]: 1. 8, 95%CI:1.69 — 1.87), age category 25—59 years (aPR: 1.9, 95%CI: 1.63 — 2.24) and ≥ 60 years (aPR: 1.8, 95%CI:1.49 — 2.12); duration on antiretroviral therapy (ART) for 6—10 years (aPR: 1.1, 95%CI:1.08 — 1.18), CD4 count ≥500 (aPR:1.3, 95%CI:1.21 — 1.30) and having at least one noncommunicable disease (NCD) (aPR: 1.1, 95%CI:1.07 — 1.18). Conclusions: There is a high burden of overweight and obesity among PLWH in Uganda. Nutrition and weight management programs particularly targeting high risk groups such as female and persons with underlying NCDs should be integrated into HIV care.

Under-nutrition and associated factors among children infected with human immunodeficiency virus in sub-Saharan Africa: a systematic review and meta-analysis

Background In the developing world, such as the sub-Saharan African region, HIV/AIDS has worsened the impact of under-nutrition in children. HIV infected children are highly vulnerable to under-nutrition. Therefore, the objective of this systematic review and meta-analysis was to estimate the pooled prevalence of under-nutrition, and the pooled effect sizes of associated factors among HIV-infected children in sub-Saharan Africa. Methods The primary studies for this review were retrieved from PubMed/ MEDLINE online, Science Direct, Hinari, web of science, CINHAL, EMBASE, WHO databases, Google, and Google Scholar databases. The articles selected for this meta-analysis were published between 2010 and 2020. The last search date was 18 October 2021. The data was extracted in Microsoft Excel format and exported to STATA Version 14.0. A random effect meta-analysis model was used. Heterogeneity was evaluated by the I2 test. The Egger weighted regression test was used to assess publication bias. Results We retrieved 847 records from these databases. Of which records, 813 were excluded due to different reasons and 34 studies were included in the final analysis. The pooled prevalence of stunting, underweight and wasting in HIV infected children was 46.7% (95% CI; 40.36–53.07, I2 = 98.7%, p < 0.01), 35.9% (95% CI; 30.79–41.02, I2 = 97.4% p < 0.01), and 23.0% (95% CI; 18.67–27.42, I2 = 96.9%, p < 0.01) respectively. The advanced WHO HIV/AIDS clinical staging (III&IV) [OR = 6.74 (95%: 1.747, 26.021), I2 = 94.7%] and household food insecurity were associated with stunting [OR = 5.92 (95% CI 3.9, 8.87), I2 = 55.7%]. Low family economic status [OR = 4.737 (95% CI: 2.605, 8.614), I2 = 31.2%] and increased feeding frequency [OR = 0.323 (95% CI: 0.172, 0.605), I2 = 69.8%] were significantly associated with under-weight. Anemia [OR = 2.860 (95% CI: 1.636, 5.000), I2 = 74.8%] and diarrhea in the previous month [OR = 4.117 (95% CI: 2.876, 5.894), I2 = 0.0%] were also associated with wasting among HIV infected children in sub-Saharan Africa. Conclusions The pooled prevalence of under-nutrition among HIV infected children was high. Nutritional assessment and interventions need great attention as a part of HIV care for HIV positive children. The implementation of policies and strategies established by national and international stakeholders in ART care centres should take a maximum emphasis on reducing under-nutrition among HIV infected children.

A public health value-based healthcare paradigm for HIV

Background HIV patients face considerable acute and chronic healthcare needs and battling the HIV epidemic remains of the utmost importance. By focusing on health outcomes in relation to the cost of care, value-based healthcare (VBHC) proposes a strategy to optimize quality of care and cost-efficiency. Its implementation may provide an answer to the increasing pressure to optimize spending in healthcare while improving patient outcomes. This paper describes a pragmatic value-based healthcare framework for HIV care. Methods A value-based HIV healthcare framework was developed during a series of roundtable discussions bringing together 16 clinical stakeholder representatives from the Belgian HIV reference centers and 2 VBHC specialists. Each round of discussions was focused on a central question translating a concept or idea to the next level of practical implementation: 1) how can VBHC principles be translated into value-based HIV care drivers; 2) how can these value-based HIV care divers be translated into value-based care objectives and activities; and 3) how can value-based HIV care objectives and activities be translated into value-based care indicators. Value drivers were linked to concrete objectives and activities using a logical framework approach. Finally, specific, measurable, and acceptable structure, process and outcomes indicators were defined to complement the framework. Results Our framework identifies 4 core value areas where HIV care would benefit most from improvements: Prevention, improvement of the cascade of care, providing patient-centered HIV care and sustaining a state-of-the-art HIV disease management context. These 4 core value areas were translated into 12 actionable core value objectives. For each objective, example activities were proposed. Indicators are suggested for each level of the framework (outcome indicators for value areas and objectives, process indicators for suggested activities). Conclusions This framework approach outlines how to define a patient- and public health centered value-based HIV care paradigm. It proposes how to translate core value drivers to practical objectives and activities and suggests defining indicators that can be used to track and improve the framework’s implementation in practice.