Longitudinal analysis of HIV outcomes for persons living with HIV in non-urban areas in southern Alberta, Canada

BACKGROUND: Many challenges remain in successfully engaging people with HIV (PWH) into lifelong HIV care. Living in non-urban or rural areas has been associated with worse outcomes. Uncertainties remain regarding how to provide optimal HIV care in non-urban areas. METHODS: Using a retrospective descriptive analysis framework, we compared multiple measurable HIV care metrics over time on the basis of urban versus non-urban residency, under a centralized HIV care model. We examined rates of HIV diagnosis, access to and retention in HIV care, and longitudinal outcomes for all newly diagnosed PWH between January 1, 2008, and January 1, 2020, categorized by their home location at the time of HIV diagnosis in southern Alberta. RESULTS: Of 719 newly diagnosed PWH, 619 (86%) lived in urban areas and 100 (14%) lived in non-urban areas. At HIV diagnosis, the groups had no significant differences in initial CD4 count or clinical characteristics ( p = 0.73). Non-urban PWH, however, had slightly longer times to accessing HIV care and initiating antiretroviral therapy (ART) ( p < 0.01). Non-urban PWH showed trends toward slightly lower retention in care and lower sustained ART use, with higher rates of unsuppressed viral loads at 12, 24, and 36 months after diagnosis ( p < 0.01). However, by 2020 both cohorts had suppression rates above 90%. CONCLUSIONS: Sustained retention in care was more challenging for non-urban PWH; however, adherence to ART and viral suppression rates was more than 90%. Although encouraging, challenges remain in identifying and reducing unique barriers for optimal care of PWH living in non-urban areas.

My family sold a cow to pay for my Traditional doctor and now there’s no money to travel to the HIV clinic: barriers to antiretroviral adherence among rural-Indigenous peoples living with HIV in the Comarca Ngäbe-Buglé, Panamá

IntroductionThe Comarca Ngäbe-Buglé (CNB) is an administratively autonomous Indigenous region in Western Panama that is home to over 200,000 individuals of Ngäbe and Buglé ethnicities. The CNB is the most impoverished region in Panama and is relatively isolated from outside influences, with limited roads, electricity, and internet connection. Around 1.5% of all rapid HIV tests are positive, compared to a national prevalence of 0.9%; in CNB, diagnosis tends to be late where 56.3% of individuals had an initial CD4 count of <350 cells/mm3. In this region, antiretroviral treatment (ART) dropout is five times higher than the national average; there is high early mortality due to opportunistic infections. This study aims to describe some of the barriers associated with ART adherence and retention in HIV care among PLHIV the CNB. A better understanding of factors that obstruct adherence could lead to more effective HIV care and prevention in CNB.MethodsWe conducted 21 semi-structured interviews with PLHIV who reside across all three regions of the CNB and who have attended an ART clinic at least once. The interviews took place between November 2018 and December 2019.DiscussionPsychological health and social support and discrimination acted as both individual-level facilitators and barriers to adherence and retention. Notably, structural barriers included difficult access to ART care due to travel costs, ART shortages, and uncooperative Western/Traditional medical systems. Recommended interventions used in other Low- and Middle-Income settings include increasing peer and family-level support and community knowledge and understanding of HIV infection. Additionally, we suggest structural interventions, including decreasing cost and distance of travel to the ART clinic through decentralization of services and multi-month dispensing, decreasing food scarcity, and increasing collaboration between Western and Traditional providers.

Durability of effects from short-term economic incentives for clinic attendance among HIV positive adults in Tanzania: long-term follow-up of a randomised controlled trial

IntroductionConditional economic incentives are shown to promote medication adherence across a range of health conditions and settings; however, any long-term harms or benefits from these time-limited interventions remain largely unevaluated. We assessed 2–3 years outcomes from a 6-month incentive programme in Tanzania that originally improved short-term retention in HIV care and medication possession.MethodsWe traced former participants in a 2013–2016 trial, which randomised 800 food-insecure adults starting HIV treatment at three clinics to receive either usual care (control) or up to 6 months of cash or food transfers (~US$11/month) contingent on timely attendance at monthly clinic appointments. The primary intention-to-treat analysis estimated 24-month and 36-month marginal risk differences (RD) between incentive and control groups for retention in care and all-cause mortality, using multiple imputation for a minority of missing outcomes. We also estimated mortality HRs from time-stratified Cox regression.ResultsFrom 3 March 2018 to 19 September 2019, we determined 36-month retention and mortality statuses for 737 (92%) and 700 (88%) participants, respectively. Overall, approximately 660 (83%) participants were in care at 36 months while 43 (5%) had died. There were no differences between groups in retention at 24 months (86.5% intervention vs 84.4% control, RD 2.1, 95% CI −5.2 to 9.3) or 36 months (83.3% vs 77.8%, RD 5.6, –2.7 to 13.8), nor in mortality at either time point. The intervention group had a lower rate of death during the first 18 months (HR 0.27, 95% CI 0.10 to 0.74); mortality was similar thereafter (HR 1.13, 95% CI 0.33 to 3.79).ConclusionThese findings confirm that incentives are a safe and effective tool to promote short-term adherence and potentially avert early deaths at the critical time of HIV treatment initiation. Complementary strategies are recommended to sustain lifelong retention in HIV care.Trial registration numberNCT01957917

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

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

Facilitators and Barriers to Retention in HIV Care among HIV Infected MSM Attending Community Health Center Yaba, Lagos Nigeria

Background: The burden of HIV infection among men who have sex with men (MSM) has posed a huge public health threat to the developing country like Nigeria. Identification of effective strategies to improve their retention in HIV care especially for young HIV infected MSM is critical for overall success in scaling down the national burden of HIV/AIDS. The aim of this study was to assess the facilitators and barriers to retention in HIV care among HIV infected MSM attending community health center, Yaba Lagos Nigeria. Methods: A two months (May –June,2016) exploratory qualitative research study was conducted among 181 respondents enrolled into HIV care within 12 months that attend community health center, Yaba Lagos Nigeria. A pretested and semi-structured questionnaire was used to collect information on the specific facilitators and barriers to retention in HIV care among respondents. Data entries and analysis were done using SPSS package version 20. Descriptive statistics was used to summarize quantitative variables, and frequency tables were generated for the relevant variables. Results: The median age (in years) of the participants sampled was 24. The study identified friendly clinic service 44%, having positive relationship with clinic staff 16%, friendly and secured environment 20% as the major facilitators to retention in HIV care while implicating distance 36% and self -denial 21% as major barriers to retention in HIV care among the respondents. Conclusion: Majority of the respondents were retained in HIV care services due to the available friendly clinic services and conducive environment instituted at the service provision site.

869. A Qualitative Review of Social Barriers Impeding Retention in HIV Care at a Ryan White Clinic

Background Ending the HIV Epidemic: A Plan for America aims to decrease new HIV diagnoses 75% by 2025 and 90% by 2030. To achieve this, we identified patients unable to achieve viral suppression with social-behavioral needs deemed ‘high-hanging fruit.’ Via extensive outreach efforts and creation of shared problem solving, we pursued the goals of rapid and effective treatment leading to viral suppression and prevention of HIV transmission. We (1) exhausted all avenues of outreach to re-engage patients in HIV care and (2) identified personal or social characteristics related to difficulties in visit retention and achieving viral suppression. Methods Of 446 Ryan White-eligible patients seen in an urban, academic medical center, 46 did not achieve and/or maintain viral suppression, and qualified for the study. We conducted a mixed methods survey comprised of both multiple choice and open-ended questions to ascertain what barriers patients face to continuous engagement in care and to achieving viral suppression. We developed a re-engagement outreach cycle which included: text messages and phone calls, electronic messages via patient portal or email, phone call to pharmacy to cross-check contact information, outreach to patients’ emergency contact, and sending a letter by mail. Results Of 46 participants, 32 were reached and 14 were not found. Sixteen re-engaged in care and of these, 14 completed the survey (see Figure). Those who completed the survey noted the following barriers to care: poor mental health, financial issues, problems committing to an appointment due to work/family/transportation, and COVID-19. Out of all 46 participants, the 14 who were not found had an overall a higher index of chaos. This index of chaos included, but was not limited to: homelessness, IV drug use, domestic violence, and stigma. Outreach to re-engage in HIV care A. Participants in study, B. Outreach outcomes, C. Common survey themes Conclusion Intensive efforts are required to re-engage patients, counsel on adherence, and achieve viral suppression. The reasons for lack of engagement in care are real and challenging. Multiple cycles of continuous outreach serve to establish trust, address barriers, and connect to HIV care. Disclosures All Authors: No reported disclosures

COVID-19 may exacerbate the clinical, structural and psychological barriers to retention in care among women living with HIV in rural and peri-urban settings in Uganda

Background Retention of pregnant and breastfeeding women and their infants in HIV care still remains low in Uganda. Recent literature has shown that the effects of COVID-19 mitigation measures may increase disease burden of common illnesses including HIV, Tuberculosis, Malaria and other key public health outcomes such as maternal mortality. A research program was undertaken to locate disengaged HIV positive women on option B+ and supported them to reengage in care. A 1 year follow up done following the tracing revealed that some women still disengaged from care. We aimed to establish the barriers to and facilitators for reengagement in care among previously traced women on option B+, and how these could have been impacted by the COVID-19 pandemic. Methods This was a cross sectional qualitative study using individual interviews conducted in June and July, 2020, a period when the COVID-19 response measures such as lockdown and restrictions on transport were being observed in Uganda. Study participants were drawn from nine peri-urban and rural public healthcare facilities. Purposive sampling was used to select women still engaged in and those who disengaged from care approximately after 1 year since they were last contacted. Seventeen participants were included. Data was analysed using the content analysis approach. Results Women reported various barriers that affected their reengagement and retention in care during the COVID-19 pandemic. These included structural barriers such as transport difficulties and financial constraints; clinical barriers which included unsupportive healthcare workers, short supply of drugs, clinic delays, lack of privacy and medicine side effects; and psychosocial barriers such as perceived or experienced stigma and non-disclosure of HIV sero-status. Supportive structures such as family, community-based medicine distribution models, and a friendly healthcare environment were key facilitators to retention in care among this group. The COVID-19 pandemic was reported to exacerbate the barriers to retention in care. Conclusions COVID-19 may exacerbate barriers to retention in HIV care among those who have experienced previous disengagement. We recommend community-based models such as drop out centres, peer facilitated distribution and community outreaches as alternative measures for access to ART during the COVID-19 pandemic.

The Kanyakla study: Randomized controlled trial of a microclinic social network intervention for promoting engagement and retention in HIV care in rural western Kenya

Background Existing social relationships are a potential source of “social capital” that can enhance support for sustained retention in HIV care. A previous pilot study of a social network-based ‘microclinic’ intervention, including group health education and facilitated HIV status disclosure, reduced disengagement from HIV care. We conducted a pragmatic randomized trial to evaluate microclinic effectiveness. Methods In nine rural health facilities in western Kenya, we randomized HIV-positive adults with a recent missed clinic visit to either participation in a microclinic or usual care (NCT02474992). We collected visit data at all clinics where participants accessed care and evaluated intervention effect on disengagement from care (≥90-day absence from care after a missed visit) and the proportion of time patients were adherent to clinic visits (‘time-in-care’). We also evaluated changes in social support, HIV status disclosure, and HIV-associated stigma. Results Of 350 eligible patients, 304 (87%) enrolled, with 154 randomized to intervention and 150 to control. Over one year of follow-up, disengagement from care was similar in intervention and control (18% vs 17%, hazard ratio 1.03, 95% CI 0.61–1.75), as was time-in-care (risk difference -2.8%, 95% CI -10.0% to +4.5%). The intervention improved social support for attending clinic appointments (+0.4 units on 5-point scale, 95% CI 0.08–0.63), HIV status disclosure to close social supports (+0.3 persons, 95% CI 0.2–0.5), and reduced stigma (-0.3 units on 5-point scale, 95% CI -0.40 to -0.17). Conclusions The data from our pragmatic randomized trial in rural western Kenya are compatible with the null hypothesis of no difference in HIV care engagement between those who participated in a microclinic intervention and those who did not, despite improvements in proposed intervention mechanisms of action. However, some benefit or harm cannot be ruled out because the confidence intervals were wide. Results differ from a prior quasi-experimental pilot study, highlighting important implementation considerations when evaluating complex social interventions for HIV care. Trial registration Clinical trial number: NCT02474992.

Why do patients interrupt and return to antiretroviral therapy? Retention in HIV care from the patient’s perspective in Johannesburg, South Africa

Background Retention in care is required for optimal clinical outcomes in people living with HIV (PLHIV). Although most PLHIV in South Africa know their HIV status, only 70% are on antiretroviral therapy (ART). Improved retention in care is needed to get closer to sustained ART for all. In January 2019, Anova Health Institute conducted a campaign to encourage patients who had interrupted ART to return to care. Methods Data collection was conducted in one region of Johannesburg. This mixed methods study consisted of two components: 1) healthcare providers entered data into a structured tool for all patients re-initiating ART at nine clinics over a nine-month period, 2) Semi-structured interviews were conducted with a sub-set of patients. Responses to the tool were analysed descriptively, we report frequencies, and percentages. A thematic approach was used to analyse participant experiences in-depth. Results 562 people re-initiated ART, 66% were women, 75% were 25–49 years old. The three most common reasons for disengagement from care were mobility (30%), ART related factors (15%), and time limitations due to work (10%). Reasons for returning included it becoming easier to attend the clinic (34%) and worry about not being on ART (19%). Mobile interview participants often forgot their medical files and expressed that managing their ART was difficult because they often needed a transfer letter to gain access to ART at another facility. On the other hand, clinics that had flexible and extended hours facilitated retention in care. Conclusion In both the quantitative data, and the qualitative analysis, changing life circumstances was the most prominent reason for disengagement from care. Health services were not perceived to be responsive to life changes or mobility, leading to disengagement. More client-centred and responsive health services should improve retention on ART.