Barriers to and Facilitators of Accessing HIV Services for Street-Involved Youth in Canada and Kenya

Introduction: UNICEF estimates that there are as many as 100 million street-involved youth (SIY) globally. Marginalized conditions put SIY at higher risk of HIV and adverse outcomes once HIV-positive. The objective of this analysis was to describe barriers and facilitators of accessing HIV prevention, testing, and treatment services as Phase I of an implementation study evaluating the use of Peer Navigators to increase access to HIV services.Methods: Semi-structured interviews, focus group discussions (FGD), and Theatre Testing were conducted with individuals who identify as SIY, health care providers, and community stakeholders living in Canada (Toronto, Montreal, London) and Kenya (Eldoret, Huruma, Kitale). Data were analyzed using a directed content approach, guided by the socio-ecological model (SEM).Results: Across the six sites were 195 participants: 64 SIY, 42 healthcare providers, and 97 community-based stakeholders. Barriers were identified at the societal (e.g. intersectional stigma and discrimination), public policy (e.g., inadequate access to basic needs, legal documentation, lack of health insurance, and limited community-based funding), institutional (e.g. lack of inclusive education and training, inadequate HIV educational outreach, and restrictive service provision), interpersonal (e.g., ineffective communication from healthcare providers), and intrapersonal levels (e.g. lack of trust and associated fear, low perception for healthcare, and lack of self-esteem). These contributed to limited HIV services utilization among SIY. Conversely, numerous facilitators were also identified at the public policy (e.g. affordable HIV services and treatment), institutional (e.g. available and accessible HIV prevention tools, HIV education and awareness programs, and holistic models of care), interpersonal level (e.g., systems navigation support, peer support, and personal relationships), and intrapersonal levels (e.g. self-efficacy) as positively supporting SIY access to HIV services.Conclusions: Intersectional stigma was a critical barrier in all sites, and policies and programs that foster welcoming environments for youth from diverse backgrounds and living circumstances may be better able to respond to the HIV service needs of this high risk population. Social support and navigation services were reported to facilitate access to HIV services in all sites.

Assessing the efficacy of an integrated intervention to create demand for fishermen’s schistosomiasis and HIV services (FISH) in Mangochi, Malawi: Study protocol for a cluster randomized control trial

Background Both HIV and schistosomiasis are major public health problems worldwide with 1.8 million new HIV infections, and up to 110 million untreated schistosomiasis cases globally. Although a causal link has not been established, there are strong suggestions that having schistosomiasis increases onward transmission of HIV from co-infected men to women. With both HIV and schistosomiasis treatment readily available in Malawi, there is a need to investigate the feasibility, acceptability and health impacts of joint management of these two hazards, with special focus on health education and demand-creation for fishermen. The aim of this project is to identify optimal models of delivering integrated HIV and schistosomiasis services for fishermen, particularly investigating the effect of using social networks, HIV self-test kits and beach clinic services in Mangochi, Malawi. Methods We have mapped 45 boat teams or landing sites for a 3-arm cluster randomized trial using “boat team” as the unit of randomization. The three arms are: 1) Standard of care (SOC) with leaflets explaining the importance of receiving presumptive treatment for schistosomiasis (praziquantel) and HIV services for fishermen, and two intervention arms of 2) SOC + a peer explaining the leaflet to his fellow fishermen in a boat team; and 3) arm 2 with HIV self-test kits delivered to the boat team fishermen by the peer. The primary outcomes measured at 9 months of trial delivery will compare differences between arms in the proportions of boat-team fishermen: 1) who self-report starting antiretroviral therapy or undergoing voluntary medical male circumcision; and 2) who have ≥1 S. haematobium egg seen on light microscopy of the filtrate from 10mls urine (“egg-positive”). Discussion This is the first evaluation of an integrated HIV and schistosomiasis services intervention for fishermen, particularly investigating the effect of using social networks, HIVST kits and beach clinic services. The findings will support future efforts to integrate HIVST with other health services for fishermen in similar settings if found to be efficacious. Trial registration This trial is registered in the ISRCTN registry: ISRCTN14354324; date of registration: 05 October 2020. https://www.isrctn.com/ISRCTN14354324?q=ISRCTN14354324&filters=&sort=&offset=1&totalResults=1&page=1&pageSize=10&searchType=basic-search. Linked to protocol version number 1.4 of 11 January 2021.

Mapping evidence on strengthened and sustained delivery early detection and management of Hypertension and Diabetes among PLWH: a scoping review protocol

ObjectiveThe main review objective of this scoping review is to identify the evidence on the patient outcomes of integrated NCD and HIV services, the type of models used, barriers and facilitators of effective integrated services for early detection and management of hypertension and diabetes in adults PLWH in primary health care settings of Low-income countries. Introduction:Non-communicable diseases (NCDs) raise global public health challenges in all population groups, but the prevalence of hypertension and diabetes is highly rising among people living with HIV (PLWH). This population group requires evidence-based care for early detection and management of hypertension and diabetes. However, there is a lack of evidence regarding the impact of integrated NCD and HIV services on outcomes of PLWH, its feasibility and effectiveness of services provision and the type of models used in strengthened and sustainable services for early detection and management of hypertension and diabetes in primary health care settings. It is necessary to map and models of integrated NCD and HIV services for PLWH and its feasibility and effectiveness as well patient outcomes in a primary health care setting in low-income countries Inclusion criteria: This scoping review will consider studies focusing on the model of integrated Non-communicable and HIV services for adult people living with HIV, including the type of models used, its feasibility, effectiveness and outcome of integrated services in primary health care settings. All published and grey literature will be included in the review. Methods: The search will be carried out using PubMed, MEDLINE with full text via EBSCO host, Google Scholar, Science Direct and Scopus, for a comprehensive search. Using MESH terms, an advanced search will be conducted and also will include grey literature through OpenGrey. This review will be restricted to studies published in English because of the feasibility of translating languages other than English. A three-step search strategy will be used, and the articles identified in the databases will be organised, and the duplicates will be removed. Two independent reviewers will review the titles and abstracts. Full texts will be imported into a bibliographic reference management system. The findings will be presented in tables and descriptive summaries.

The risks and benefits of providing HIV services during the COVID-19 pandemic

Introduction The COVID-19 pandemic has caused widespread disruptions including to health services. In the early response to the pandemic many countries restricted population movements and some health services were suspended or limited. In late 2020 and early 2021 some countries re-imposed restrictions. Health authorities need to balance the potential harms of additional SARS-CoV-2 transmission due to contacts associated with health services against the benefits of those services, including fewer new HIV infections and deaths. This paper examines these trade-offs for select HIV services. Methods We used four HIV simulation models (Goals, HIV Synthesis, Optima HIV and EMOD) to estimate the benefits of continuing HIV services in terms of fewer new HIV infections and deaths. We used three COVID-19 transmission models (Covasim, Cooper/Smith and a simple contact model) to estimate the additional deaths due to SARS-CoV-2 transmission among health workers and clients. We examined four HIV services: voluntary medical male circumcision, HIV diagnostic testing, viral load testing and programs to prevent mother-to-child transmission. We compared COVID-19 deaths in 2020 and 2021 with HIV deaths occurring now and over the next 50 years discounted to present value. The models were applied to countries with a range of HIV and COVID-19 epidemics. Results Maintaining these HIV services could lead to additional COVID-19 deaths of 0.002 to 0.15 per 10,000 clients. HIV-related deaths averted are estimated to be much larger, 19–146 discounted deaths per 10,000 clients. Discussion While there is some additional short-term risk of SARS-CoV-2 transmission associated with providing HIV services, the risk of additional COVID-19 deaths is at least 100 times less than the HIV deaths averted by those services. Ministries of Health need to take into account many factors in deciding when and how to offer essential health services during the COVID-19 pandemic. This work shows that the benefits of continuing key HIV services are far larger than the risks of additional SARS-CoV-2 transmission.

Social Influences on Engagement With HIV Testing, Treatment and Care Services Among Men Who Have Sex With Men Living in Rural Uganda

Men who have sex with men in Uganda are a heterogenous, discriminated population, experiencing high HIV burden, limited access to HIV testing, and low treatment adherence. We contribute to the lack of information about men who have sex with men in rural Uganda by using socio-ecological analyses to examine the social influences shaping their engagement with HIV services. Based on in-depth interviews with 16 men, our findings reveal the inhibitive influence of interpersonal relationships with sexual partners, peers and families, and institutional influences within health service and non-governmental organizational settings. Yet men take action to strategize and seek support to enhance engagement with HIV care in heavily criminalized and stigmatized settings. Future HIV prevention, testing, treatment, and care responses could draw on what affected individuals and communities are already doing to enhance access to HIV services and the effective support strategies of some non-governmental organizations and healthcare workers.

Sexual Risk Behaviors, HIV Prevalence and Access to Reproductive Health Services Among Young Women Migrant Workers in the Industrial Zones in Vietnam

Background: Young migrant workers working in the industrial zones (IZ) in low and middle-income countries are at risk for HIV and other sexually transmitted diseases. This study examines the sex-related risks of young women migrant workers in the IZ in Vietnam.Materials and Methods: This cross-sectional survey was conducted among 1,061 young migrant women working in the IZ park in Hanoi, Vietnam. Multivariate logistic regression analysis was used to identify factors associated with HIV testing and condom use at last sex.Results: A total of 1,061 young women migrant workers completed the survey in which 652 participants consented to take the initial rapid HIV test. All but one participant tested negative indicating a HIV prevalence of 150 (95% CI: 27–860) per 100,000 population among this population. There were no differences in sexual behavior, use of sexual and reproductive health services, HIV knowledge, perceived HIV risk or alcohol use between those who were HIV tested and those not tested. Single participants reported high rates of first sex while living in the IZ and high rates of condom use during the first-time sex, however, they had low levels of condom use at last sex. While the majority of married participants used the SRH/HIV services, nearly 80% of the single participants who reported having sex never used SRH/HIV services since living in the IZ. However, single participants were over 4 times more likely to use condoms at last sex compared to married participants (OR = 4.67; 95%CI = 2.96–7.85). Participants with vocational school or higher education was more likely to use condom (OR = 2.19; 95%CI = 1.05–4.57). Neither HIV knowledge or alcohol use were associated with condom use.Conclusions: Although HIV prevalence is very low among young women workers in the IZ in Vietnam, a significant number of them engaged in risky sexual behavior and low levels of condom use at last sex as well as low level of using SRH/HIV services highlights a need to develop interventions that provide tailored-made and cultural appropriate SRH education for unmarried female migrant workers to prevent risky sexual behaviors, sexually transmitted diseases and unwanted pregnancy.

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.

Bottlenecks and Opportunities towards Achieving the Targeted 95-95-95 HIV Services in a Rural District in Eastern Uganda

Background: There are 1.3 million people living with HIV in Uganda of which 73% know their HIV-positive status, 67% of the HIV-positive patients on ART, and 60% are viral load suppressed. Uganda has made progress in reducing the HIV prevalence from 7.3% in 2011 to 6% in 2017, however, more needs to be done to meet the WHO target of 95% of the population knowing their HIV status, 95% enrolled on treatment and 95% achieving viral suppression. This study aimed to assess the bottlenecks and opportunities towards achieving the 95 95 95 targeted HIV services in Bukedea district. Methods: A mixed-methods cross-sectional study was conducted in Bukedea district covering males and females aged 18-65 years who had consented to participate in the study. We used a purposive sampling procedure to select our study participants. Qualitative data was collected through focus group discussions, key informant interviews, and document reviews for quantitative data. Quantitative data were analyzed using STATA v 14 whereas qualitative data were analyzed using the thematic analysis approach. Results: The challenges were grouped as patient-related, medication-related, and facility-related challenges. The patient-related challenges were stigma, fear to take the drugs, poor nutrition, long distances, alcoholism, busy working schedules, domestic violence. The medication-related 2 challenges were side effects, pill burden. The facility-related challenges were inadequate pretest counseling, stockouts. The use of anti-retroviral drugs was common in piggery and poultry and the sources of these drugs were reported to be the people on ART and the health workers. The opportunities included home-based counseling, organizing more outreaches, counseling and health education, targeted testing, and strengthening the VHT networks. Conclusion: The study revealed that the major challenges towards achieving the targeted 95-95- 95 HIV services were stigma, inadequate pre-test counseling, fear of disclosure, and poor adherence due to alcoholism, sharing of drugs with animals and partners. The use of Antiretroviral drugs in animal husbandry was common in Bukedea District. Continuous sensitization about HIV and the importance of adherence to drugs, continuous and adequate counseling of the clients on ART, and close monitoring of their viral load could help to improve enrollment into care, adherence to HIV treatment, and HIV viral load suppression.

A realist evaluation of the continuum of HIV services for men who have sex with men

Background Men who have Sex with Men (MSM) represent the risk group that are disproportionately most affected by the human immunodeficiency virus (HIV) and continue to drop-off from the steps of the continuum of HIV services that have been adopted to overcome poor engagement and retention in care. This realist evaluation aimed at: (1) describing the evaluation carried out in Haiti aiming to ascertain why, how and under which circumstances MSM are linked and retained along the continuum, (2) assessing the outcomes of this approach and (3) exploring the motivators and facilitators for the HIV continuum of services through mechanisms and pathways. Methods Guided by a realist approach, first, an initial program theory (IPT) was developed based on literature and frameworks review, participant observations and discussions with stakeholders. Then, the IPT was tested using a mixed method explanatory study: a quantitative phase to build the continuum from a cross-sectional analysis, and a qualitative phase to explore the motivators and facilitators related to proper linkages along the continuum. Finally, the IPT was refined by eliciting the mechanisms and pathways for outcomes improvement. Results The results showed that the current service delivery model is suboptimal in identifying, engaging, linking and retaining MSM, resulting in loss to follow-up at every step of the continuum and failure to fully realize the health and prevention benefits of antiretroviral. However, the mechanisms through which linkages across the continuum can be improved are: self-acceptance, sense of community support and sense of comprehensive and tailored HIV services. These mechanisms are based on 10 different pathways: self-esteem, awareness and pride, perception of HIV risk, pcceptance and HIV status, addressing community stigma, strengthening of MSM organizations and community networks, societal acceptation and tolerance, stigma reduction training for healthcare providers, engagement of peers as educators and navigators and, adapted services delivery through drug dispensing points and mobile technology and financial assistance. Conclusions The study findings show that engagement, adherence and retention to the continuum of HIV service for MSM are affected by a multi-layer of factors, thus highlighting the importance of taking a comprehensive approach to improve the program.