Impact of Community Support Workers in Rural Ethiopia on Emotional and Psychosocial Health of Persons Living with HIV: Results of a Three-Year Randomized Community Trial.

People living with HIV face multiple psychosocial challenges. In a large, predominantly rural Ethiopian region, 1799 HIV patients new to care were enrolled from 32 sites in a cluster randomized trial using trained community support workers with HIV to provide individual health education, counseling and social support. Participants received annual surveys through 36 months using items drawn from the Centre for Epidemiologic Studies Depression Scale-10, Medical Outcome Study Social Support Survey, and HIV/AIDS Stigma Instrument-PLWA. At 12 months (using linear mixed effects regression models controlling for enrollment site clustering), intervention participants had greater emotional/informational and tangible assistance social support scores, and lower scores assessing depression symptoms and negative self-perception due to HIV status. A significant treatment effect at 36 months was also seen on scores assessing emotional/informational social support, depression symptoms, and internalized stigma. An intervention using peer community support workers with HIV to provide individualized informational and psychological support had a positive impact on the emotional health of people living with HIV who were new to care.(ClinicalTrials.gov protocol ID: 1410S54203, May 19, 2015).

A three-year randomized community trial of community support workers in rural Ethiopia to promote retention in HIV care.

Retention in care is a major challenge for global AIDS control, including sub-Saharan Africa. In a large Ethiopian region, we evaluated an intervention where HIV positive community support workers (CSWs) provided HIV health education, personal counseling and social support for HIV patients new to care. We enrolled 1,799 patients recently entering care from 32 hospitals and health centers, randomized to intervention or control sites. Dates of all clinic visits, plus deaths or transfers were abstracted from HIV medical records. Primary outcomes were gap in clinical care (>90 days from a missed clinical or drug pickup appointment) and death. For 36 months of follow-up, and for the first 12 months after enrollment, weighted risk differences [RD] between treatment arms were modest and non-significant for gap in clinical care, death or either outcome. Through 36 months, 624 of 980 controls and 469 of 819 intervention participants had gaps in clinical care (RD = -5.5%, 95% confidence interval [CI] = -17.9%, 7.0%); 79 controls and 82 intervention participants died (RD = 2.5% 95% CI = -1.7%, 6.8%). Factors including HIV stigma and a volatile political climate may have attenuated the advantages we anticipated, demonstrating how benefits of CSW interventions may depend upon psychosocial, clinical and structural factors particular to specific community settings.

Disclosure of HIV status among patients new to HIV care in Southern Ethiopia: role of perceived social support and other factors.

Reports from Sub-Saharan Africa, with a large HIV-infected population, vary widely in how often HIV status is disclosed to others, including spouses and other partners. We surveyed 1799 Ethiopian HIV patients newly enrolled in care within the previous 3 months at one of 32 local hospitals and health centers about disclosure of HIV status and two perceived social support domains: emotional/informational (EI) and tangible assistance (TA) support. Disclosure to another person was reported by 1389 (77%) persons. Disclosure rates to specific persons were: spouses or other partners = 74%; mothers = 24%; fathers = 16%; children = 26%; other family members = 37%; friends = 19%, and neighbors/other community members = 13%. Disclosure to another person was associated with higher social support scores on both EI and TA domains, marriage, and a longer time knowing HIV status. In multivariate adjusted models, disclosure to any person, as well as disclosure specifically to a spouse or partner, were associated with higher EI and higher TA social support scores. Provision of knowledgeable and emotionally supportive assistance can be an important factor in facilitating HIV disclosure. Helping persons with HIV decide who to disclose to and how to do so in the most positive manner is an essential component of HIV care and support.

Advanced HIV Disease among Males and Females Initiating HIV Care in Rural Ethiopia.

Despite recommendations for rapidly initiating HIV treatment, many persons in sub-Saharan Africa present to care with advanced HIV disease. Baseline survey and clinical data were collected on 1799 adults newly enrolling at 32 district hospitals and local health HIV clinics in rural Ethiopia. Among those with complete HIV disease information, advanced HIV disease (defined as CD4 count <200 cells/mm3 or World Health Organization [WHO] HIV clinical stage III or IV disease) was present in 66% of males and 56% of females ( P < .001). Males (compared to females) had lower CD4 counts (287 cells/mm3 versus 345 cells/mm3), lower body mass index (19.3 kg/m2 versus 20.2 kg/m2), and more WHO stage III or IV disease (46% versus 37%), ( P < .001). Men reported more chronic diarrhea, fevers, cough, pain, fatigue, and weight loss ( P < .05). Most initiating care in this resource-limited setting had advanced HIV disease. Men had poorer health status, supporting the importance of earlier diagnosis, linkage to care, and initiation of antiretroviral therapy.

A multi-site community randomized trial of community health workers to provide counseling and support for patients newly entering HIV care in rural Ethiopia: study design and baseline implementation.

BACKGROUND: Although HIV therapy is delivered to millions globally, treatment default (especially soon after entering care) remains a challenge. Community health workers (CHWs) can provide many services for people with HIV, including in rural and resource-limited settings. OBJECTIVES: We designed and implemented a 32 site community randomized trial throughout southern Ethiopia to assess an intervention using CHWs to improve retention in HIV care. METHODS: Sixteen district hospital and 16 local health center HIV clinics were randomized 1:1 to be intervention or control sites. From each site, we enrolled adults newly entering HIV care. Participants at intervention sites were assigned a CHW who provided: HIV and health education; counseling and social support; and facilitated communication with HIV clinics. All participants are followed through three years with annual health surveys, plus HIV clinic record abstraction including clinic visit dates. CHWs record operational data about their client contacts. RESULTS: 1799 HIV patients meeting inclusion criteria were enrolled and randomized: 59% were female, median age = 32 years, median CD4 + count = 263 cells/mm3, and 41% were WHO Stage III or IV. A major enrollment challenge was fewer new HIV patients initiating care at participating sites due to shortage of HIV test kits. At intervention sites, 71 CHWs were hired, trained and assigned to clients. In meeting with clients, CHWs needed to accommodate to various challenges, including HIV stigma, distance, and clients lacking cell phones. CONCLUSIONS: This randomized community HIV trial using CHWs in a resource-limited setting was successfully launched, but required flexibility to adapt to unforeseen challenges.

Frequent Use of Khat, an Amphetamine-Like Substance, as a Risk Factor for Poor Adherence and Lost to Follow-Up Among Patients New to HIV Care in Ethiopia.

Khat, a plant native to East Africa, has amphetamine-like psychoactive constituents, and is a potential risk factor for HIV infection. Chronic use can cause cognitive impairment and other mental disorders, raising concerns about effects on retention and adherence with HIV care. During 2013-2014, 322 Ethiopian patients newly enrolled at HIV clinics in Dire Dawa and Harar were surveyed about khat use and prospectively followed for 1 year; 9% died, 18% transferred care to other clinics, and 22% were lost to follow-up (LTFU) (no clinic visit for >3 months). Of 248 patients who received a 12-month follow-up survey, 37% used khat in the year after enrollment, with a median use of 60 h in a typical month. Those using khat ≥60 h/month (median among users) were more likely than others to be LTFU (31% vs. 16%, p = .014); those using khat ≥150 h/month (upper quartile) had 44% LTFU rates versus 16% for others (p = .002). Complete 3-day adherence (taking all doses) of antiretroviral therapy was reported by 77% of those using khat ≥60 h/month versus 95% of all others (p < .001), and 67% of those using khat ≥150 h/month versus 94% of others (p < .001). In two East African cities, where khat use is common, frequent use was a significant risk factor for higher 1-year LTFU and lower self-reported antiretroviral therapy adherence among people living with HIV entering HIV care. Where khat is widely utilized, interventions to promote either nonuse or reduced use are important as part of a comprehensive HIV care package and national HIV strategies.

Prevalence and factors associated with use of khat: a survey of patients entering HIV treatment programs in Ethiopia.

BACKGROUND: Khat, a plant native to East Africa, has psychoactive constituents similar to amphetamine. Chronic khat use can lead to psychological dependence with multiple physical and mental health harms, complicating clinical management of people living with HIV. In two Ethiopian cities where khat is common, we evaluated prevalence and correlates of khat use among patients new to HIV care. METHODS: During 2013-2014, we surveyed 322 patients recently enrolled in HIV clinics in Dire Dawa and Harar about khat use, demographics, smoking and alcohol use, clinical illness, food insecurity, and social support. We analyzed factors associated with khat use in the past year, as well as heaviest use of khat (based on greatest number of hours used in a typical month). RESULTS: 242 (75%) respondents reported lifetime khat use; 209 (65%) reported khat use during the previous year. 54% of khat users started before age 19 years. Although 84% believed that using khat every day is dangerous for health if you have HIV, khat was used in the previous year a median of 5 h/days and 30 days/month; 21% said they felt a need to cut down or control their khat use but had difficulty doing so. Those using khat were more likely to report smoking (46%) and alcohol use (49%) compared to non-khat users (1 and 31% respectively). Those reporting heaviest khat use (≥180 h/typical month) were more likely to rate their health status as poor, have an underweight BMI (≤18.5 kg/m2), report more symptoms of chronic illness, and agree with more statements indicating a negative physical quality of life. In multivariate analysis, heavy users were more likely to be male, Muslim, and non-married. CONCLUSIONS: Khat use was common among HIV patients entering care, and associated with symptoms of poorer physical health. Over half started khat use when they were young. Although most believed khat is harmful for HIV patients, a number of respondents reported some difficulty controlling their drug use. In settings where khat is legal and widely utilized, developing interventions for responsible use represent an important health priority as part of comprehensive care for people living with HIV.