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Test but not treat: Community members' experiences with barriers and facilitators to universal antiretroviral therapy uptake in rural KwaZulu-Natal, South Africa.

ABSTRACT: INTRODUCTION:Antiretroviral therapy (ART) has revolutionised the care of HIV-positive individuals resulting in marked decreases in morbidity and mortality, and markedly reduced transmission to sexual partners. However, these benefits can only be realised if individuals are aware of their HIV-positive status, initiated and retained on suppressive lifelong ART. Framed using the socio-ecological model, the present study explores factors contributing to poor ART uptake among community members despite high acceptance of HIV-testing within a Treatment as Prevention (TasP) trial. In this paper we identify barriers and facilitators to treatment across different levels of the socio-ecological framework covering individual, community and health system components. METHODS:This research was embedded within a cluster-randomised trial (ClinicalTrials.gov, number NCT01509508) of HIV treatment as Prevention in rural KwaZulu-Natal, South Africa. Data were collected between January 2013 and July 2014 from resident community members. Ten participants contributed to repeat in-depth interviews whilst 42 participants took part in repeat focus group discussions. Data from individual interviews and focus group discussions were triangulated using community walks to give insights into community members' perception of the barriers and facilitators of ART uptake. We used thematic analysis guided by a socio-ecological framework to analyse participants' narratives from both individual interviews and focus group discussions. RESULTS:Barriers and facilitators operating at the individual, community and health system levels influence ART uptake. Stigma was an over-arching barrier, across all three levels and expressed variably as fear of HIV disclosure, concerns about segregated HIV clinical services and negative community religious perceptions. Other barriers were individual (substance misuse, fear of ART side effects), community (alternative health beliefs). Facilitators cited by participants included individual (expectations of improved health and longer life expectancy following ART, single tablet regimens), community (availability of ART in the community through mobile trial facilities) and health system factors (fast and efficient service provided by friendly staff). DISCUSSION:We identified multiple barriers to achieving universal ART uptake. To enhance uptake in HIV care services, and achieve the full benefits of ART requires interventions that tackle persistent HIV stigma, and offer people with HIV respectful, convenient and efficient services. These interventions require evaluation in appropriately designed studies.

SUBMITTER: Iwuji C

PROVIDER: S-EPMC7514038 | biostudies-literature | 2020

REPOSITORIES: biostudies-literature

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Test but not treat: Community members' experiences with barriers and facilitators to universal antiretroviral therapy uptake in rural KwaZulu-Natal, South Africa.

Iwuji Collins C Chimukuche Rujeko Samanthia RS Zuma Thembelihle T Plazy Melanie M Larmarange Joseph J Orne-Gliemann Joanna J Siedner Mark M Shahmanesh Maryam M Seeley Janet J

PloS one 20200924 9

<h4>Introduction</h4>Antiretroviral therapy (ART) has revolutionised the care of HIV-positive individuals resulting in marked decreases in morbidity and mortality, and markedly reduced transmission to sexual partners. However, these benefits can only be realised if individuals are aware of their HIV-positive status, initiated and retained on suppressive lifelong ART. Framed using the socio-ecological model, the present study explores factors contributing to poor ART uptake among community member ...[more]

PMID: 32970730

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Project description:ObjectiveIntegration of mental health and chronic disease services in primary care could reduce the mental health treatment gap and improve associated health outcomes in low-resource settings. Low rates of nurse identification and referral of patients with depression limit the effectiveness of integrated mental health care; the barriers to and facilitators of identification and referral in South Africa and comparable settings remain undefined. This study explored barriers to and facilitators of nurse identification and referral of patients with depressive symptoms as part of integrated mental health service delivery in KwaZulu-Natal, South Africa.DesignTriangulation mixed methods study incorporating qualitative and quantitative data.MethodsData collection, analysis, and interpretation were guided by the Consolidated Framework for Implementation Research (CFIR). Participants were professional nurses at ten primary health care facilities in Amajuba, KwaZulu-Natal, South Africa. Qualitative data collection involved semi-structured interviews targeting specific CFIR constructs with high- and low-referring nurses. Deductive and inductive coding were used to derive primary themes related to barriers and facilitators. Quantitative data collection involved a structured questionnaire assessing determinants explored in the interviews. Qualitative comparative analysis was used to identify the necessary or sufficient conditions for high and low nurse referral.ResultsTwenty-two nurses were interviewed. Primary themes related to insufficient training, supervision, and competency; emotional burden; limited human and physical resources; perceived patient need for integrated services; and intervention acceptability. Sixty-eight nurses completed questionnaires. Quantitative results confirmed and expanded upon the qualitative findings. Low self-assessed competency was a consistent barrier to appropriate service delivery.ConclusionsTo promote the success of integrated care in a context of severe staff shortages and over-burdened providers, implementation strategies including direct training, structured supervision, and routine behavioral health screening tools are warranted. Interventions to improve mental health literacy of patients as well as emotional support for nurses are also needed.

Project description:BACKGROUND:The transgender population has unique health risks, including increased risk of mental illness, substance abuse, suicide and a high prevalence of human immunodeficiency virus (HIV). Worldwide studies indicate that this population is marginalised and faces barriers in accessing health care. In South Africa, there is limited information and research on the transgender population's interaction with health services. AIM:The purpose of this study was to examine the experiences of the transgender population in accessing health care facilities for sexual and reproductive needs. SETTING:The study took place in KwaZulu-Natal province of South Africa. METHODS:A qualitative study combining phenomenological and critical ethnographic approaches was conducted to explore the experiences of the transgender population in the health care setting. Critical ethnography was chosen because it is an emancipatory method that highlights the plight of disenfranchised groups, and phenomenology was used to illuminate experiences of the transgender population. Purposive snowball sampling was applied to select nine transgender participants who had experiences of contact with a health care setting. Data collection was performed through semi-structured interviews and a focus group discussion. RESULTS:Participants provided details about the paucity of facilities, resources and targeted programmes to cater for the transgender populations' sexual and reproductive health needs. The participants engage in high-risk behaviour, comprising unprotected sex and use of cross-gender hormones without medical supervision. Furthermore, the participants reported experiences of hostile and discriminatory behaviour by healthcare workers. CONCLUSION:It emerged that there is a paucity of resources and knowledge to provide appropriate health care services to the transgender population, resulting in adverse experiences. Policies on transgender care and training of health workers will contribute towards improvement of health care access for the transgender population.

Project description:BackgroundSince mental health may influence HIV care among people living with HIV (PLHIV), we sought to evaluate the impact of anxiety and depression on ART initiation and HIV-related outcomes.MethodsWe conducted a prospective cohort study of PLHIV in the Umlazi Township of KwaZulu-Natal, South Africa. We measured depression using the Patient Health Questionnaire (PHQ-9) and anxiety using the Generalized Anxiety Disorder (GAD-7) scale, both of which have been validated in sub-Saharan Africa, among all patients prior to receiving a positive HIV test. We then followed those who tested HIV+ for 12 months to determine their time to ART initiation, missing clinic visits or refills, retention in care, hospitalization, and death. We used logistic regression models, adjusted for socio-demographic characteristics such as age and sex, to examine the effects of baseline measures of depression and anxiety on ART initiation and HIV treatment outcomes.FindingsAmong 2,319 adult PLHIV, mean age was 33 years (SD=9.3 years), 57% were female, and baseline median CD4 count was 317 cells/mm3 (IQR=175-491 cells/mm3). In univariate analyses, depression was associated with slower rates of ART initiation. In adjusted models, PLHIV with depression had lower odds of initiating ART within 90 days of HIV testing (aOR=0.60, 95% CI=0.46, 0.79, p<0.01), and lower odds of being retained in care (aOR=0.77, 95% CI=0.60, 0.99, p = 0.04). By the end of the 12-month study period, odds of ART initiation among PLHIV with depression were higher than the first 90 days but still significantly lower compared to those without depression (aOR=0.72, 95% CI=0.52, 0.99, p = 0.04). Among PLHIV who initiated ART, depression was associated with a lower odds of missing clinic visits (aOR=0.54, 95% CI= 0.40, 0.73, p<0.01). Anxiety was strongly correlated with depression (r = 0.77, p<0.01) and had similar effects on HIV-related outcomes.InterpretationsThe presence of depression is a significant barrier to ART initiation and retention in care among adult PLHIV in South Africa. Mental health screenings around the time of HIV testing may help improve linkage and HIV-related outcomes.FundingThis work was supported by the Infectious Disease Society of America Education & Research Foundation and National Foundation for Infectious Diseases (PKD); Massachusetts General Hospital Executive Committee on Research (PKD); the Harvard University Center for AIDS Research [AI060354] (PKD); and the National Institute of Allergy and Infectious Diseases [AI108293, AI143351] (PKD). The content is solely the responsibility of the authors and does not represent the official views of the National Institutes of Health or other funding agencies.

Dataset Information

Test but not treat: Community members' experiences with barriers and facilitators to universal antiretroviral therapy uptake in rural KwaZulu-Natal, South Africa.

Publications

Test but not treat: Community members' experiences with barriers and facilitators to universal antiretroviral therapy uptake in rural KwaZulu-Natal, South Africa.

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