Factors associated with adherence to ARV treatment in people living with HIV/AIDS in a rural area (Koula-Moutou) in East Gabon

The goal of this study was to evaluate the impact of socio-clinical factors on adherence to antiretroviral treatment in people living with HIV/AIDS in Koula-Moutou (a rural area of Gabon). Two adherence assessment methods based on patient declaration and compliance with pharmacy visits were used to determine qualitative and quantitative aspects of adherence to antiretroviral therapy (ART). The quantitative (82.2%) and qualitative (79.5%) adherences to ART declared by patients were higher than those obtained through pharmacy visit assessment methods (15.8% and 45.2%, respectively). Moreover, the declarative and pharmacy visit compliance methods showed fair agreement (quantitative Kappa = 0.317; qualitative Kappa = 0.311). A better quantitative or qualitative declarative adherence was associated with a lower level of education (P = 0.05 and P = 0.025 respectively). This study reported for the first time the factors influencing adherence to ART in a rural area of East Gabon. We recommend further investigations in a large cohort to better assess the impact of socio-clinical factors on ART adherence in a vulnerable group of patients

A qualitative analysis of the barriers to antiretroviral therapy initiation among children 2 to 18 months of age in Swaziland

HIV/AIDS remains one of the leading causes of death among children under 5 years old in Swaziland. Although studies have shown that early initiation of infants and children diagnosed with HIV on antiretroviral therapy (ART) significantly reduces mortality, many children do not initiate ART until the later stages of disease. This study was designed to collect qualitative data from mothers and caregivers of HIV-positive children to identify the barriers to ART initiation. Focus group discussion (FGD) sessions were conducted in siSwati between July and September 2014 among caregivers of aged children 2­18 months in Swaziland who did or did not initiate ART between January 2011 and December 2012 after HIV DNA PCR-positive diagnosis of the infants. Denial, guilt, lack of knowledge, tuberculosis (TB)/HIV co-infection, HIV-related stigma, lack of money, and distance to clinics were reported by the participants as barriers to ART initiation. The findings further revealed that non-initiation on ART was not linked to a negative perception of the treatment. Findings suggest a need to improve sensitivity among healthcare workers as well as education and counselling services that will facilitate the ART initiation process

HIV-serostatus disclosure in the context of free antiretroviral therapy and socio-economic dependency: experiences among women living with HIV in Tanzania

The worldwide implementation of free antiretroviral therapy (ART) raised great hopes among policy makers and health organisations about the positive changes it would bring about in attitudes and behaviours towards HIV and AIDS; as well as for infected people's lives. A change in illness perception was anticipated; leading to the hypothesis of a possible change in disclosure rates; patterns and the choice of significant others to inform. In the era of free treatment availability in the United Republic of Tanzania; we examined reasons for disclosure and non-disclosure among HIV-seropositive women enrolled on ART and their choice of significant others to inform. In so doing; we contribute to the necessary yet neglected debate about the social impact of ART on the lives of infected women. The study; for which an ethnographic cross-sectional pilot approach was chosen; was conducted at the Care and Treatment Center (CTC) at Bombo Regional Hospital (BRH) in Tanga city; Tanzania. Data presented here derive from participant observation; questionnaires and semi-structured interviews conducted with 59 HIV-seropositive women on ART. Interestingly; and despite treatment availability; the choice of significant others to inform; as well as reasons for disclosure and non-disclosure; mirror findings from previous studies conducted before the introduction of free ART. The main reason for non-disclosure was fear of discrimination. The hope for social; economic or health support was the main motivation for disclosure; followed by the need for a 'clinic companion' in order to receive ART; as requested by hospital staff. Nevertheless; healthcare staff were not unanimous in thinking that disclosure is always beneficial; thus the recommended extent of disclosure varied. ART and concomitant factors were raised as an entirely new and significant reason for disclosure by interviewees. Finally; findings confirm that despite ART; disclosure remains a highly stressful event for women

Obstacles to HIV prevention, treatment and care in selected public universities in South Africa

South Africa; like the rest of Southern Africa; is ravaged by AIDS. Higher education in South Africa has a significant role to play in the fight against the spread of HIV and AIDS. This article reports the factors contributing to the spread of HIV and AIDS in three selected public universities in South Africa. To achieve the stated aim; the study answered the following research question: What are the factors contributing to the spread of HIV and AIDS in South African public universities? The problem in this study stems from South Africa's HIV and AIDS infection rate; one of the highest in the world; especially in KwaZulu-Natal. A qualitative approach was adopted by conducting focus group interviews with the students. The data were analysed using axial coding and open coding; where dominant themes from the discussions were identified and discussed in detail. The findings show that barriers to HIV and AIDS prevention; care and treatment exist in the tertiary institutions under study. Social and economic interventions are needed to stem the spread of HIV and AIDS at tertiary institutions. A range of recommendations for halting the spread of HIV and AIDS in these institutions is provided

Reproductive behaviour among women on antiretroviral therapy in Botswana: mismatched pregnancy plans and contraceptive use

Understanding pregnancy planning and contraceptive use is important in preventing unplanned/unwanted pregnancies among women on antiretroviral therapy (ART). Through a cross-sectional survey of 155 women living with HIV on ART in Botswana (mean age = 36); bivariate/multivariate analyses were used to identify and understand pregnancy planning and contraceptive use. Women who did not plan to have a child (n = 85) were older; less educated; had more children and worried about stigmatisation from family and healthcare workers (HCWs). Multivariate analyses found age (OR:3.41; CI:1.57-7.45; p = 0.002); perceived stigmatisation from family and healthcare workers (OR:3.62; CI:1.47-8.96; p = 0.005); and believing it is irresponsible for women living with HIV to want a child (OR:2.40; CI:1.10-5.24; p = 0.028) to be significantly associated with not planning to have a child. Although reported condom use among 85 women who did not plan to have a child was nearly 90; a total of 26 of these women (34) believed they did not have control over condom use. Lack of contraception was reported by 6 women who did not plan a child; this; coupled with the lack of control over condom use; puts unmet need for contraception at 38 Most women reported feeling comfortable talking with HCWs about contraceptives. However; almost a quarter of the women indicated they were infrequently advised about contraceptives at ART clinics. This study found discordance between pregnancy planning and contraceptive use among women on ART. Lack of control over condom use coupled with low hormonal contraceptive use creates unmet need for contraception and increases the risk of unwanted pregnancies. Regular clinic visits for women on ART present excellent opportunities to address contraceptive needs in a considerate and comprehensive manner

Mobile health for early retention in HIV care: a qualitative study in Kenya (WelTel Retain)

Many people newly diagnosed with HIV are lost to follow-up before timely initiation of antiretroviral therapy (ART). A randomised controlled trial (RCT); WelTel Kenya1; demonstrated the effectiveness of the WelTel text messaging intervention to improve clinical outcomes among patients initiating ART. In preparation for WelTel Retain; an RCT that will evaluate the effect of the intervention to retain patients in care immediately following HIV diagnosis; we conducted an informative qualitative study with people living with HIV (n = 15) and healthcare providers (HCP) (n = 5) in October 2012. Study objectives included exploring the experiences of people living with HIV who have attempted to engage in HIV care; the use of cell phones in everyday life; and perceptions of communicating via text message with HCP. Participants were recruited through convenience sampling. Semi-structured; qualitative interviews were conducted and recorded; transcribed verbatim and analysed using NVivo software. Analysis was guided by the Theory of Reasoned Action and the Technology Acceptance Model. Results indicate that while individuals have many motivators for engaging in care after diagnosis; structural and individual barriers including poverty; depression and fear of stigma prevent them from doing so. All participants had access to a mobile phone; and most were comfortable communicating through text messages; or were willing to learn. Both people living with HIV and HCP felt that increased communication via the text messaging intervention has the potential to enable early identification of problems; leading to timely problem solving that may improve retention and engagement in care during the first year after diagnosis

A Pharmacovigilance Study of Adults on Highly Active Antiretroviral Therapy; South Africa: 2007-2011

Background: Of the 1.6 million South African people infected with human immunodeficiency virus (HIV); approximately 970;000 (55) have been initiated on HAART. Despite these numbers; very little has been published about the safety profile of antiretroviral (ARV) medicines in the country. This study was performed at the Medunsa National Pharmacovigilance Centre and aimed to describe the demographic characteristics of patients enrolled in the pharmacovigilance surveillance study; highly active antiretroviral therapy (HAART) initiation regimen patterns; reasons for regimen changes; and adverse effects of ARV medicines. Methods: A cohort study of HIV-infected individuals aged 15 years or older who were on ARV medicines was conducted at four sentinel sites. Results: After HAART initiation; with an average lapse of 17.8 months (range: 0 - 83.8 months); 2;815 patients were enrolled into the study. Results show that patients were observed for 1;606.2 person-years for pharmacy visits (collection of ARV medicines) and 817.1 person-years for clinical visits (consultation with the doctor). Females constituted 69.6 (1;958/2;815) of the study population. Almost all patients initiated HAART on first-line regimens (2;801/2;815). Some patients (6.7; 190/2;815) dropped out of the study after HAART initiation. Reasons for regimen changes were not recorded for 2.5(22/891) of the patients who changed regimens. The primary reason for regimen changes was drug-related toxicity (76.1; 678/891); mostly evident in patients taking first-line regimens. Adverse effects experienced by patients were polyneuropathy (24.0; 163/678); lipodystrophy (23.9; 162/678); neuropathy (10.6; 72/678); and suspected lactic acidosis (3.8; 26/678). Conclusion: The majority of prescribers complied with the HAART guidelines and initiated most patients on first-line regimens. However; adverse effects are evident in patients taking first-line regimens. We recommend that the Department of Health should introduce less toxic first-line ARV regimens. Future efforts will aim to initiate patients on HAART and enrol them into the study simultaneously to determine early risk profiles of ARV medicines

Scaling up antiretroviral therapy for HIV-infected children in Côte d'Ivoire: determinants of survival and loss to programme

Objective: To investigate deaths and losses to follow-up in a programme designed to scale up antiretroviral therapy (ART) for HIV- infected children in Cote d'Ivoire. Methods Between 2004 and 2007; HIV-exposed children at 19 centres were offered free HIV serum tests (polymerase chain reaction tests in those aged 18 months) and ART. Computerized monitoring was used to determine: (i) the number of confirmed HIV infections; (ii) losses to the programme (i.e. death or loss to follow-up) before ART; (iii) mortality and loss-to-programme rates during 12 months of ART; and (iv) determinants of mortality and losses to the programme. Findings The analysis included 3876 ART-naive children. Of the 1766 with HIV-1 infections (17aged 18 months); 124 (7.0) died; 52 (2.9) left the programme; 354 (20) were lost to follow-up before ART; 259 (15) remained in care without ART; and 977 (55) started ART (median age: 63 months). The overall mortality rate during ART was significantly higher in the first 3 months than in months 4-12: 32.8 and 6.9 per 100 child-years of follow-up; respectively. Loss-to-programme rates were roughly double mortality rates and followed the same trend with duration of ART. Independent predictors of 12-month mortality on ART were pre-ART weight- for-age z-score -2; percentage of CD4+ T lymphocytes 10; World Health Organization HIV/AIDS clinical stage 3 or 4; and blood haemoglobin 8 g/dl. Conclusion The large-scale programme to scale up paediatric ART in Cote d'Ivoire was effective. However; ART was often given too late; and early mortality and losses to programme before and just after ART initiation were major problems

Scale-up of a decentralized HIV treatment programme in rural KwaZulu-Natal, South Africa: does rapid expansion affect patient outcomes?

Objective:To describe the scale-up of a decentralized HIV treatment programme delivered through the primary health care system in rural KwaZulu-Natal, South Africa, and to assess trends in baseline characteristics and outcomes in the study population Methods The programme started delivery of antiretroviral therapy (ART) in October 2004. Information on all patients initiated on ART was captured in the programme database and follow-up status was updated monthly. All adult patients (≥ 16 years) who initiated ART between October 2004 and September 2008 were included and stratified into 6-month groups. Clinical and sociodemographic characteristics were compared between the groups. Retention in care, mortality, loss to follow-up and virological outcomes were assessed at 12 months post-ART initiation.Findings A total of 5719 adults initiated on ART were included (67.9% female). Median baseline CD4+ lymphocyte count was 116 cells/µl (interquartile range, IQR: 53­173). There was an increase in the proportion of women who initiated ART while pregnant but no change in other baseline characteristics over time. Overall retention in care at 12 months was 84.0% (95% confidence interval, CI: 82.6­85.3); 10.9% died (95% CI: 9.8­12.0); 3.7% were lost to follow-up (95% CI: 3.0­4.4). Mortality was highest in the first 3 months after ART initiation: 30.1 deaths per 100 person­years (95% CI: 26.3­34.5). At 12 months 23.0% had a detectable viral load (> 25 copies/ml) (95% CI: 19.5­25.5).Conclusion Outcomes were not affected by rapid expansion of this decentralized HIV treatment programme. The relatively high rates of detectable viral load highlight the need for further efforts to improve the quality of services

The Implications of HIV Infection on the Management of Valvular Heart Disease in Southern Africa

There is very limited information on the disease profi le and treatment approaches in HIV patients with valvular heart disease (VHD) in developing countries. HIV infection impacts on patients with VHD in three settings: HIV/ Aids as a comorbid disease in patients with underlying valve disease; infective endocarditis secondary to immunosuppression; and non-infective valve involvement from myocardial failure or from marantic endocarditis. The clinical presentation of infective endocarditis does not differ between HIV and non-HIV patients; with the exception that intravenous drug abuse is a common cause in specific populations. While peri-operative mortality and morbidity is high in acute infective endocarditis; surgical interventions do not increase the postoperative risk for complications or death and should therefore not be withheld. There is also little evidence to suggest that HIV or antiretroviral drugs increase the rate of cardiac-related pregnancy complications or that pregnancy may alter the course of HIV infection. Since antiretroviral therapy has been associated with considerable improvement in clinical status prior to surgery; as well as in long term outcomes; all patients with valve disease in whom intervention is likely should undergo HIV testing and staging so that highly active antiretroviral treatment (HAART) may be instituted timeously. Conclusion: The high prevalence of HIV in our population makes consideration of this comorbidity an essential facet in the routine evaluation and management of patients with VHD. There is solid evidence that these patients do no worse than non-HIV patients undergoing medical treatment or percutaneous/surgical intervention - open-heart surgery may be offered safely to patients with HIV if proper precautions are taken

A clinical and epidemiologic update on the interaction between tuberculosis and human immunodeficiency virus infection in adults

Background : Tuberculosis (TB) is an important cause of mortality and morbidity in human immunodeficiency virus (HIV) infection in Africa. The interaction between TB and HIV infections is reviewed. Methods : Literature on TB; HIV and their co-infection; especially in sub-Saharan Africa; including Nigeria; is reviewed. Results : Burden of TB is fueled by the HIV epidemic; and clinical presentation of TB may be atypical with co-infection. Recommendations on drugs and timing of antiretroviral therapy (ART) initiation are discussed. Use of cotrimoxazole prophylaxis (CPT) in co-infected patients reduces morbidity and mortality; while the principles of TB prevention in HIV infection can be summarized with the three I's: intensive TB case finding and surveillance; isoniazid preventive therapy (IPT) and infection-control measures; to these can be added a fourth 'I;' viz.; instituting ART. Clinical complications like drug resistance; toxicity and drug interactions; and immune reconstitution inflammatory syndrome (IRIS) with CPT; IPT and ART are highlighted. Emergence of drug-resistant- and nosocomial- TB in HIV infection poses serious challenges and potential consequences in Africa; and appropriate measures are recommended. Conclusions : Many barriers exist for optimizing the care of the two diseases; but the aim should be strengthening capacities; collaborations; linkages and eventually integrating the services. Interventions for TB prevention in HIV infection should be widely implemented