A cohort study to assess a communication intervention to improve linkage to HIV care in Nakivale Refugee Settlement, Uganda.

Communication interventions to enhance linkage to HIV care have been successful in sub-Saharan Africa but have not been assessed among refugees. Refugees and Ugandan nationals participating in HIV testing in Nakivale Refugee Settlement were offered weekly phone call and short message service (SMS) reminders. We assessed linkage to care and predictors of linkage within 90 days of testing, comparing Intervention participants to those unwilling or ineligible to participate (Non-Intervention). Of 208 individuals diagnosed with HIV, 101 (49%) participated in the intervention. No difference existed between Intervention and Non-intervention groups in linkage to care (73 [72%] vs. 76 [71%], p = 0.88). Excluding those who linked prior to receipt of intervention, the intervention improved linkage (69 [68%] vs. 50 [47%], p = 0.002). Participants were more likely to link if they were older (aOR 2.39 [1.31, 4.37], p = 0.005) or Ugandan nationals (aOR 3.76 [1.12, 12.66], p = 0.033). Although the communication intervention did not significantly improve linkage to HIV care, the linkage was improved when excluding those with same-day linkage. Excluding participants without a phone was a significant limitation; these data are meant to inform more rigorous designs moving forward. Innovative methods to improve linkage to HIV care for this vulnerable population are urgently needed.

A Social-Ecological Framework to Understand Barriers to HIV Clinic Attendance in Nakivale Refugee Settlement in Uganda: a Qualitative Study.

The social-ecological model proposes that efforts to modify health behaviors are influenced by constraints and facilitators at multiple levels. We conducted semi-structured interviews with 47 clients in HIV care and 8 HIV clinic staff to explore how such constraints and facilitators (individual, social environment, physical environment, and policies) affect engaging in HIV clinical care in Nakivale Refugee Settlement in Uganda. Thematic analysis revealed that participants were motivated to attend the HIV clinic because of the perceived quality of services and the belief that antiretroviral therapy improves health. Barriers to clinic attendance included distance, cost, unemployment, and climate. Those that disclosed their status had help in overcoming barriers to HIV care. Nondisclosure and stigma disrupted community support in overcoming these obstacles. Interventions to facilitate safe disclosure, mobilize social support, and provide more flexible HIV services may help overcome barriers to HIV care in this setting.

Feasibility and acceptability of home-based HIV testing among refugees: a pilot study in Nakivale refugee settlement in southwestern Uganda.

BACKGROUND: Refugees in sub-Saharan Africa face both the risk of HIV infection and barriers to HIV testing. We conducted a pilot study to determine the feasibility and acceptability of home-based HIV testing in Nakivale Refugee Settlement in Uganda and to compare home-based and clinic-based testing participants in Nakivale. METHODS: From February-March 2014, we visited homes in 3 villages in Nakivale up to 3 times and offered HIV testing. We enrolled adults who spoke English, Kiswahili, Kinyarwanda, or Runyankore; some were refugees and some Ugandan nationals. We surveyed them about their socio-demographic characteristics. We evaluated the proportion of individuals encountered (feasibility) and assessed participation in HIV testing among those encountered (acceptability). We compared characteristics of home-based and clinic-based testers (from a prior study in Nakivale) using Wilcoxon rank sum and Pearson's chi-square tests. We examined the relationship between a limited number of factors (time of visit, sex, and number of individuals at home) on willingness to test, using logistic regression models with the generalized estimating equations approach to account for clustering. RESULTS: Of 566 adults living in 319 homes, we encountered 507 (feasibility = 90%): 353 (62%) were present at visit one, 127 (22%) additional people at visit two, and 27 (5%) additional people at visit three. Home-based HIV testing participants totaled 378 (acceptability = 75%). Compared to clinic-based testers, home-based testers were older (median age 30 [IQR 24-40] vs 28 [IQR 22-37], p < 0.001), more likely refugee than Ugandan national (93% vs 79%, < 0.001), and more likely to live ≥1 h from clinic (74% vs 52%, < 0.001). The HIV prevalence was lower, but not significantly, in home-based compared to clinic-based testing participants (1.9 vs 3.4% respectively, p = 0.27). Testing was not associated with time of visit (p = 0.50) or sex (p = 0.66), but for each additional person at home, the odds of accepting HIV testing increased by over 50% (OR 1.52, 95%CI 1.12-2.06, p = 0.007). CONCLUSIONS: Home-based HIV testing in Nakivale Refugee Settlement was feasible, with 90% of eligible individuals encountered within 3 visits, and acceptable with 75% willing to test for HIV, with a yield of nearly 2% individuals tested identified as HIV-positive.

A qualitative approach to understand antiretroviral therapy (ART) adherence for refugees living in Nakivale Refugee Settlement in Uganda.

BACKGROUND: Refugees living with HIV in sub-Saharan Africa suffer unique hardships that may increase their vulnerability to interruptions in antiretroviral therapy (ART). METHODS: To investigate refugees' experiences adhering to ART, we conducted inperson interviews with refugees on ART (n = 73) and HIV clinic staff (n = 4) in Nakivale Refugee Settlement in southwest Uganda from March to July 2011. Three analysts used a conventional content analysis approach to evaluate these data. RESULTS: Refugees described profound motivation to adhere to ART and employed adherence strategies to facilitate success despite the austere setting. However, refugees spoke of specific hardships living in Nakivale that served as barriers to ART adherence, including difficulty accessing clinic when ill, food insecurity, drug stockouts, and violence and unrest in the settlement. For some refugees, need for ART inextricably linked them to the HIV clinic and prevented them from transitioning permanently away from the settlement. CONCLUSIONS: By learning about refugees' experiences we can design informed interventions to enhance ART adherence, thus minimizing morbidity and mortality, preventing transmission of HIV, and supporting refugees' abilities to move freely toward repatriation, resettlement or integration in their host country.

The role of social support on HIV testing and treatment adherence: A qualitative study of HIV-infected refugees in southwestern Uganda.

Little is known about the factors that encourage or discourage refugees to test for HIV, or to access and adhere to HIV care. In non-refugee populations, social support has been shown to influence HIV testing and utilisation of services. The present study enrolled HIV-infected refugees on anti-retroviral therapy (ART) in Uganda, who participated in qualitative interviews on HIV testing, treatment, and adherence. Interviews were analysed for themes about four types of social support: emotional, informational, instrumental, and appraisal support. A total of 61 interviews were analysed. Four roles for these types of social support were identified: (1) informational support encouraged refugees to test for HIV; (2) emotional support helped refugees cope with a diagnosis of HIV; (3) instrumental support facilitated adherence to ART and (4) after diagnosis, HIV-infected refugees provided informational and emotional support to encourage other refugees to test for HIV. These results suggest that social support influences HIV testing and treatment among refugees. Future interventions should capitalise on social support within a refugee settlement to facilitate testing and treatment.

Predictors of HIV infection: a prospective HIV screening study in a Ugandan refugee settlement.

BACKGROUND: The instability faced by refugees may place them at increased risk of exposure to HIV infection. Nakivale Refugee Settlement in southwestern Uganda hosts 68,000 refugees from 11 countries, many with high HIV prevalence. We implemented an HIV screening program in Nakivale and examined factors associated with new HIV diagnosis. METHODS: From March 2013-November 2014, we offered free HIV screening to all clients in the Nakivale Health Center while they waited for their outpatient clinic visit. Clients included refugees and Ugandan nationals accessing services in the settlement. Prior to receiving the HIV test result, participants were surveyed to obtain demographic information including gender, marital status, travel time to reach clinic, refugee status, and history of prior HIV testing. We compared variables for HIV-infected and non-infected clients using Pearson's chi-square test, and used multivariable binomial regression models to identify predictors of HIV infection. RESULTS: During the HIV screening intervention period, 330 (4%) of 7766 individuals tested were identified as HIV-infected. Refugees were one quarter as likely as Ugandan nationals to be HIV-infected (aRR 0.27 [0.21, 0.34], p < 0.0001). Additionally, being female (aRR 1.43 [1.14, 1.80], p = 0.002) and traveling more than 1 h to the clinic (aRR 1.39 [1.11, 1.74], p = 0.003) increased the likelihood of being HIV-infected. Compared to individuals who were married or in a stable relationship, being divorced/separated/widowed increased the risk of being HIV-infected (aRR 2.41 [1.88, 3.08], p < 0.0001), while being single reduced the risk (aRR 0.60 [0.41, 0.86], p < 0.0001). Having been previously tested for HIV (aRR 0.59 [0.47, 0.74], p < 0.0001) also lowered the likelihood of being HIV-infected. CONCLUSIONS: In an HIV screening program in a refugee settlement in Uganda, Ugandan nationals are at higher risk of having HIV than refugees. The high HIV prevalence among clients seeking outpatient care, including Ugandan nationals and refugees, warrants enhanced HIV screening services in Nakivale and in the surrounding region. Findings from this research may be relevant for other refugee settlements in Sub-Saharan Africa hosting populations with similar demographics, including the 9 other refugee settlements in Uganda.

Clinic-based routine voluntary HIV testing in a refugee settlement in Uganda.

We implemented and evaluated a clinic-based routine voluntary HIV testing intervention in Nakivale Refugee Settlement in Uganda. Comparing the standard of care period (40 d) with the intervention period (168 d), the mean HIV-infected clients identified per week increased from 0.9 to 5.6, and there was no significant difference between the HIV prevalence in the 2 periods (standard of care: 3.3%; intervention: 4.5%; P > 0.5). Clinic-based routine HIV testing in a refugee settlement is effective and should be considered for implementation in refugee settlements in other high-prevalence regions in sub-Saharan Africa.

Testing experiences of HIV positive refugees in Nakivale Refugee Settlement in Uganda: informing interventions to encourage priority shifting.

BACKGROUND: Recent initiatives by international health and humanitarian aid organizations have focused increased attention on making HIV testing services more widely available to vulnerable populations. To realize potential health benefits from new services, they must be utilized. This research addresses the question of how utilization of testing services might be encouraged and increased for refugees displaced by conflict, to make better use of existing resources. METHODS: Open-ended interviews were conducted with HIV-infected refugees (N=73) who had tested for HIV and with HIV clinic staff (N=4) in Nakivale Refugee Settlement in southwest Uganda. Interviews focused on accessibility of HIV/AIDS-related testing and care and perspectives on how to improve utilization of testing services. Data collection took place at the Nakivale HIV/AIDS Clinic from March to July of 2011. An inductive approach to data analysis was used to identify factors related to utilization. RESULTS: In general, interviewees report focusing daily effort on tasks aimed at meeting survival needs. HIV testing is not prioritized over these responsibilities. Under some circumstances, however, HIV testing occurs. This happens when: (a) circumstances realign to trigger a temporary shift in priorities away from daily survival-related tasks; (b) survival needs are temporarily met; and/or (c) conditions shift to alleviate barriers to HIV testing. CONCLUSION: HIV testing services provided for refugees must be not just available, but also utilized. Understanding what makes HIV testing possible for refugees who have tested can inform interventions to increase testing in this population. Intervening by encouraging priority shifts toward HIV testing, by helping ensure survival needs are met, and by eliminating barriers to testing, may result in refugees making better use of existing testing services.