Qualitative exploration of perceived benefits of care and barriers influencing HIV care in trans Nzoia, Kenya.

BACKGROUND: Substantial efforts have been made to ensure people living with HIV (PLHIV) are linked to and retained in care but many challenges deter care utilization. We report perceived benefits of seeking HIV care and barriers to HIV care that were identified through a formative assessment conducted to advise the development of an alternative care model to deliver antiretroviral treatment therapy (ART) in Trans Nzoia County, Kenya. METHODS: Data were collected in 2015 through key informant interviews (KIIs), in-depth interviews (IDIs), and focus group discussions (FGDs). The study involved 55 participants of whom 53% were female. Ten KIIs provided community contextual information and viewpoints on the HIV epidemic in Trans Nzoia County while 20 PLHIV (10 male and 10 female) participated in IDIs. Twenty-five individuals living with HIV participated in four FGDs - two groups for men and two for women. Key informants were purposively selected, while every third patient above 18 years at the Kitale HIV Clinic was invited to share their HIV care experience through IDIs or FGDs. Trained research assistants moderated all sessions and audio recordings were transcribed and analyzed thematically. RESULTS: Findings showed that PLHIV in Trans Nzoia County used both conventional and complementary alternative care for HIV; however, public health facilities were preferred. Popular perceived benefits of adopting care were relief from symptoms and the chance to live longer. Benefits of care uptake included weight gain, renewed energy, and positive behavior change. Individual-level barriers to HIV care included lack of money and food, use of alternative care, negative side effects of ART, denial, and disclosure difficulties. At the community level, stigma, limited social support for conventional HIV treatment, and poor means of transport were reported. The health system barriers were limited supplies and staff, long distance to conventional HIV care, and unprofessional providers. CONCLUSIONS: Diverse individual, community and health system barriers continue to affect HIV care-seeking efforts in Kenya. Appreciation of context and lived experiences allows for development of realistic care models.

Strategies for delivery of HIV test results in population-based HIV seroprevalence surveys: a review of the evidence.

OBJECTIVES: Many population-based demographic surveys assess local and national HIV prevalence in developing countries through home-based HIV testing and counselling (HBHTC), but results are rarely returned to participants. This review gathered evidence on the feasibility and best practices of providing HIV test results during such surveys by reviewing population-based surveys that provided test results. STUDY DESIGN: Literature review. METHODS: This review was conducted as part of a broader literature review related to HBHTC. We present results from population-based HIV seroprevalence surveys conducted between January 1984 and June 2013. RESULTS: We identified eighteen population-based surveys describing uptake of results when testing or results were offered in the home, four of which compare home uptake to facility-based testing. All were from Sub-Saharan Africa. More people tested and received results in HBHTC compared to facility-based testing. Uptake of test results (72%) and the percentage of the population tested (59%) was highest when testing and the provision of results were provided in the home compared to the provision of results elsewhere (41% uptake; 37% population coverage), as well as mobile/facility-based testing and the provision of results (15% uptake; 13% population coverage). Providing results the same day as testing in HBHTC produces higher uptake (97% uptake; 74% population coverage) than delayed results. CONCLUSIONS: Inclusion of home testing and provision of HIV results to participants in national population-based surveys in Sub-Saharan Africa is possible and should be prioritized. The timing and location of testing and the provision of results during HBHTC as part of population-based surveys affects uptake of testing and population coverage.

Provider-initiated HIV testing in health care settings: should it include client-centered counselling?

To increase access to HIV testing, the WHO and CDC have recommended implementing provider-initiated HIV testing (PITC). To address the resource limitations of the PITC setting, WHO and CDC suggest that patient-provider interactions during PITC may need to focus on providing information and referrals, instead of engaging patients in client-centered counselling, as is recommended during client-initiated HIV testing. Providing HIV prevention information has been shown to be less effective than client-centered counselling in reducing HIV-risk behaviour and STI incidence. Therefore, concerns exist about the efficacy of PITC as an HIV prevention approach. However, reductions in HIV incidence may be greater if more people know their HIV status through expanded availability of PITC, even if PITC is a less effective prevention intervention than is client-initiated HIV testing for individual patients. In the absence of an answer to this public health question, adaptation of effective brief client-centered counselling approaches to PITC should be explored along with research assessing the efficacy of PITC.

Home-based HIV voluntary counseling and testing in developing countries.

BACKGROUND: The low uptake of HIV voluntary counseling and testing (VCT), an effective HIV prevention intervention, has hindered global attempts to prevent new HIV infections, as well as limiting the scale-up of HIV care and treatment for the estimated 38 million infected persons. According to UNAIDS, only 10% of HIV-infected individuals worldwide are aware of their HIV status. At this point in the HIV epidemic, a renewed focus has shifted to prevention, and with it, a focus on methods to increase the uptake of HIV VCT. This review discusses home-based HIV VCT delivery models, which, given the low uptake of facility-based testing models, may be an effective avenue to get more patients on treatment and prevent new infections. OBJECTIVES: (1) To identify and critically appraise studies addressing the implementation of home-based HIV voluntary counseling and testing in developing countries.(2) To determine whether home-based HIV voluntary counseling and testing (HBVCT) is associated with improvement in HIV testing outcomes compared to facility-based models. SEARCH STRATEGY: We searched online for published and unpublished studies in MEDLINE (February 2007), EMBASE (February 2007), CENTRAL (February 2007). We also searched databases listing conference proceedings and abstracts; AIDSearch (February 2007), The Cochrane Library (Issue 2, 2007), LILACS, CINAHL and Sociofile. We also contacted authors who have published on the subject of review. SELECTION CRITERIA: We searched for randomized controlled trials (RCTs) and non-randomized trials (e.g., cohort, pre/post-intervention and other observational studies) comparing home-based HIV VCT against other testing models. DATA COLLECTION AND ANALYSIS: We independently selected studies, assessed study quality and extracted data. We expressed findings as odds ratios (OR), and relative Risk (RR) together with their 95% confidence intervals (CI). MAIN RESULTS: We identified one cluster-randomized trial and one pre/post-intervention (cohort) study, which were included in the review. An additional two ongoing RCTs were identified. All identified studies were conducted in developing countries. The two included studies comprised one cluster-randomized trial conducted in an urban area in Lusaka, Zambia and one pre/post-intervention (cohort) study, part of a rural community cohort in Southwestern Uganda. The two studies, while differing in methodology, found very high acceptability and uptake of VCT when testing and or results were offered at home, compared to the standard (facility-based testing and results). In the cluster-randomized trial (n=849), subjects randomized to an optional testing location (including home-based testing) were 4.6 times more likely to accept VCT than those in the facility arm (RR 4.6, 95% CI 3.6-6.2). Similarly, in the pre/post study (n=1868) offering participants the option of home delivery of results increased VCT uptake. In the intervention year (home delivery) participants were 5.23 times more likely to receive their results than during the year when results were available only at the facility. (OR 5.23 95% CI 4.02-6.8). AUTHORS' CONCLUSIONS: Home-based testing and/or delivery of HIV test results at home, rather than in clinics, appears to lead to higher uptake in testing. However, given the limited extant literature and the limitations in the included existing studies, there is not sufficient evidence to recommend large-scale implementation of the home-based testing model.

Morbidity and mortality among diabetic patients admitted to Mulago Hospital, Uganda.

OBJECTIVES: To document the causes of admission, clinical presentation and outcome of patients admitted with diabetes mellitus to our medical wards. SETTING: Medical wards of Mulago Hospital, teaching hospital and national referral for the government of Uganda. STUDY DESIGN: Cross-sectional descriptive non-interventional study of diabetic medical admissions. RESULTS: During the study period 129 (4.2%) patients with diabetes mellitus out of 3103 total medical admissions were admitted. The commonest cause of admission was uncontrolled diabetes (48.3%) but infections were present in 27.7% of all the study patients. The commonest infections were pneumonia (15%) and urinary tract infections (11.8%). Diabetic ketoacidosis (DKA) was a cause of admission in 9.2% of all the study subjects. Glycaemic control was satisfactory among 50.6% (HbA1c less than 7) despite 84.5% of the study subjects being hyperglycaemic at admission (mean random blood sugar 20±9.0 mmol/L). Fifty-point seven of the subjects had long term complications of diabetes at admission with hypertension (53.8%) and peripheral neuropathy (38.3%) being the commonest. There were 13 deaths (10.8%) and 61.5% of the deaths were among patients admitted with infections. The average length of hospitalisation was 9.5±4 days. CONCLUSION: The results show that the commonest causes of admission were uncontrolled diabetes and infections. The mortality rate was 10.8%.