Caroline Masquillier

Impact of community-based support services on antiretroviral treatment programme delivery and outcomes in resource-limited countries: a synthetic review

BackgroundTask-shifting to lay community health providers is increasingly suggested as a potential strategy to overcome the barriers to sustainable antiretroviral treatment (ART) scale-up in high-HIV-prevalence, resource-limited settings. The dearth of systematic scientific evidence on the contributory role and function of these forms of community mobilisation has rendered a formal evaluation of the published results of existing community support programmes a research priority.MethodsWe reviewed the relevant published work for the period from November 2003 to December 2011 in accordance with the guidelines for a synthetic review. ISI Web of Knowledge, Science Direct, BioMed Central, OVID Medline, PubMed, Social Services Abstracts, and Sociological Abstracts and a number of relevant websites were searched.ResultsThe reviewed literature reported an unambiguous positive impact of community support on a wide range of aspects, including access, coverage, adherence, virological and immunological outcomes, patient retention and survival. Looking at the mechanisms through which community support can impact ART programmes, the review indicates that community support initiatives are a promising strategy to address five often cited challenges to ART scale-up, namely (1) the lack of integration of ART services into the general health system; (2) the growing need for comprehensive care, (3) patient empowerment, (4) and defaulter tracing; and (5) the crippling shortage in human resources for health. The literature indicates that by linking HIV/AIDS-care to other primary health care programmes, by providing psychosocial care in addition to the technical-medical care from nurses and doctors, by empowering patients towards self-management and by tracing defaulters, well-organised community support initiatives are a vital part of any sustainable public-sector ART programme.ConclusionsThe review demonstrates that community support initiatives are a potentially effective strategy to address the growing shortage of health workers, and to broaden care to accommodate the needs associated with chronic HIV/AIDS. The existing evidence suggests that community support programmes, although not necessarily cheap or easy, remain a good investment to improve coverage of communities with much needed health services, such as ART. For this reason, health policy makers, managers, and providers must acknowledge and strengthen the role of community support in the fight against HIV/AIDS.

A peer adherence support intervention to improve the antiretroviral treatment outcomes of HIV patients in South Africa: the moderating role of family dynamics

Given the severe shortage of human resources in the healthcare sector in many countries with high HIV prevalence, community-based peer adherence support is being increasingly cited as an integral part of a sustainable antiretroviral treatment (ART) strategy. However, the available scientific evidence on this topic reports discrepant findings on the effectiveness of peer adherence support programmes. These conflicting findings to some extent can be attributed to the lack of attention to the social contexts in which peer adherence support programmes are implemented. This study explores the potential moderating role of family dynamics by assessing the differential impact of peer adherence support in different types of families, based on the theoretical underpinnings of the family functioning framework. These relationships were explored with the aid of multivariate statistical analysis of cross-sectional, post-trial data for a sample of 340 patients interviewed as part of the Effectiveness of Aids Treatment and Support in the Free State (FEATS) study conducted in the public-sector ART programme of the Free State Province of South Africa. The analysis reveals no significant overall differences in CD4 cell count between the intervention group accessing additional peer adherence support and the control group receiving standard care. When controlling for the potential moderating role of family dynamics, however, the outcomes clearly reveal a significant interaction effect between the adherence intervention and the level of family functioning with regard to treatment outcomes. Multi-group analysis demonstrates that peer adherence support has a positive effect on immunological restoration in well-functioning families, while having a negative effect in dysfunctional families. The study outcomes stress the need for peer adherence interventions that are sensitive to the suboptimal contexts in which they are often implemented. Generic, broad-based interventions do not necessarily facilitate the treatment adherence of the most vulnerable patient groups, particularly those without supportive family contexts. Tailoring interventions aimed at creating a health-enabling environment to the needs of these at-risk patients should therefore be a priority for both research and policy.

The impact of community support initiatives on the stigma experienced by people living with HIV/AIDS in South Africa.

In the current context of human resource shortages in South Africa, various community support interventions are being implemented to provide long-term psychosocial care to persons living with HIV/AIDS (PLWHA). However, it is important to analyze the unintended social side effects of such interventions in regards to the stigma felt by PLWHA, which might threaten the successful management of life-long treatment. Latent cross-lagged modeling was used to analyze longitudinal data on 294 PLWHA from a randomized controlled trial (1) to determine whether peer adherence support (PAS) and treatment buddying influence the stigma experienced by PLWHA; and (2) to analyze the interrelationships between each support form and stigma. Results indicate that having a treatment buddy decreases felt stigma scores, while receiving PAS increases levels of felt stigma at the second follow up. However, the PAS intervention was also found to have a positive influence on having a treatment buddy at this time. Furthermore,xa0a treatment buddy mitigates the stigmatizing effect of PAS, resulting in a small negative indirect effect on stigma. The study indicates the importance of lookingxa0beyond the intended effects of an intervention, with the goal of minimizing any adverse consequences that might threaten the successful long-term management of HIV/AIDS and maximizing the opportunities created by such support.

Families as catalysts for peer adherence support in enhancing hope for people living with HIV/AIDS in South Africa

Hope is an essential dimension of successful coping in the context of illnesses such as HIV/AIDS, because positive expectations for the future alleviate emotional distress, enhance quality of life and have been linked to the capacity for behavioural change. The social environment (e.g. family, peers) is a regulator of hope for people living with HIV/AIDS (PLWHA). In this regard, the dual aim of this article is (1) to analyze the influence of a peer adherence support (PAS) intervention and the family environment on the state of hope in PLWHA and (2) to investigate the interrelationship between the two determinants.

Measuring health-related quality of life of HIV-positive adolescents in resource-constrained settings.

Background and Objectives Access to antiretroviral treatment among adolescents living with HIV (ALH) is increasing. Health-related quality of life (HRQOL) is relevant for monitoring the impact of the disease on both well-being and treatment outcomes. However, adequate screening tools to assess HRQOL in low-resource settings are scarce. This study aims to fill this research gap, by 1) assessing the psychometric properties and reliability of an Eastern African English version of a European HRQOL scale for adolescents (KIDSCREEN) and 2) determining which version of the KIDSCREEN (52-, 27- and 10-item version) is most suitable for low-resource settings. Methods The KIDSCREEN was translated into Eastern African English, Luganda (Uganda) and Dholuo (Kenya) according to standard procedures. The reconciled version was administered in 2011 to ALH aged 13–17 in Kenya (nu200a=u200a283) and Uganda (nu200a=u200a299). All three KIDSCREEN versions were fitted to the data with confirmatory factor analysis (CFA). After comparison, the most suitable version was adapted based on the CFA outcomes utilizing the results of previous formative research. In order to develop a general HRQOL factor, a second-order measurement model was fitted to the data. Results The CFA results showed that without adjustments, the KIDSCREEN cannot be used for measuring the HRQOL of HIV-positive adolescents. After comparison, the most suitable version for low-resource settings - the 27-item version - was adapted further. The introduction of a negative wording factor was required for the Dholuo model. The Dholuo (CFI: 0.93; RMSEA: 0.039) and the Luganda model (CFI: 0.90; RMSEA: 0.052) showed a good fit. All cronbach’s alphas of the factors were 0.70 or above. The alpha value of the Dholuo and Lugandan HRQOL second-order factor was respectively 0.84 and 0.87. Conclusions The study showed that the adapted KIDSCREEN-27 is an adequate tool for measuring HRQOL in low-resource settings with high HIV prevalence.

The Importance of the Family: A Longitudinal Study of the Predictors of Depression in HIV Patients in South Africa

As a chronic illness, HIV/AIDS requires life-long treatment adherence and retention—and thus sufficient attention to the psychosocial dimensions of chronic disease care in order to produce favourable antiretroviral treatment (ART) outcomes in a sustainable manner. Given the high prevalence of depression in chronic HIV patients, there is a clear need for further research into the determinants of depression in this population. In order to comprehensively study the predictors of depressive symptoms in HIV patients on ART, the socio-ecological theory postulates to not only incorporate the dominant individual-level and the more recent community-level approaches, but also incorporate the intermediate, but crucial family-level approach. The present study aims to extend the current literature by simultaneously investigating the impact of a wide range individual-level, family-level and community-level determinants of depression in a sample of 435 patients enrolled in the Free State Province of South Africa public-sector ART program. Structural equation modeling is used to explore the relationships between both latent and manifest variables at two time points. Besides a number of individual-level correlates—namely education, internalized and external stigma, and avoidant and seeking social support coping styles—of depressive symptoms in HIV patients on ART, the study also revealed the important role of family functioning in predicting depression. While family attachment emerged as the only factor to continuously and negatively impact depression at both time points, the second dimension of family functioning, changeability, was the only factor to produce a negative cross-lagged effect on depression. The immediate and long-term impact of family functioning on depression draws attention to the role of family dynamics in the mental health of people living with HIV/AIDS. In addition to individual-level and community-based factors, future research activities should also incorporate the role of the family context in research into the mental health of HIV patients, as our results demonstrate that the familial context in which a person with HIV on ART resides is inextricably interconnected with his/her health outcomes.

HIV/AIDS competent households: Interaction between a health-enabling environment and community-based treatment adherence support for people living with HIV/AIDS in South Africa

In the context of severe human resource shortages in HIV care, task-shifting and especially community-based support are increasingly being cited as potential means of providing durable care to chronic HIV patients. Socio-ecological theory clearly stipulates that–in all social interventions–the interrelatedness and interdependency between individuals and their immediate social contexts should be taken into account. People living with HIV/AIDS (PLWHA) seldom live in isolation, yet community-based interventions for supporting chronic HIV patients have largely ignored the social contexts in which they are implemented. Research is thus required to investigate such community-based support within its context. The aim of this study is to address this research gap by examining the way in which HIV/AIDS competence in the household hampers or facilitates community-based treatment adherence support. The data was analyzed carefully in accordance with the Grounded Theory procedures, using Nvivo 10. More specifically, we analyzed field notes from participatory observations conducted during 48 community-based treatment adherence support sessions in townships on the outskirts of Cape Town, transcripts of 32 audio-recorded in-depth interviews with PLWHA and transcripts of 4 focus group discussions with 36 community health workers (CHWs). Despite the fact that the CHWs try to present themselves as not being openly associated with HIV/AIDS services, results show that the presence of a CHW is often seen as a marker of the disease. Depending on the HIV/AIDS competence in the household, this association can challenge the patient’s hybrid identity management and his/her attempt to regulate the interference of the household in the disease management. The results deepen our understanding of how the degree of HIV/AIDS competence present in a PLWHA’s household affects the manner in which the CHW can perform his or her job and the associated benefits for the patient and his/her household members. In this respect, a household with a high level of HIV/AIDS competence will be more receptive to treatment adherence support, as the patient is more likely to allow interaction between the CHW and the household. In contrast, in a household which exhibits limited characteristics of HIV/AIDS competence, interaction with the treatment adherence supporter may be difficult in the beginning. In such a situation, visits from the CHW threaten the hybrid identity management. If the CHW handles this situation cautiously and the patient–acting as a gate keeper–allows interaction, the CHW may be able to help the household develop towards HIV/AIDS competence. This would have a more added value compared to a household which was more HIV/AIDS competent from the outset. This study indicates that pre-existing dynamics in a patient’s social environment, such as the HIV/AIDS competence of the household, should be taken into account when designing community-based treatment adherence programs in order to provide long-term quality care, treatment and support in the context of human resource shortages.

The Development and Piloting of Parallel Scales Measuring External and Internal HIV and Tuberculosis Stigma Among Healthcare Workers in the Free State Province, South Africa

BACKGROUNDnThe dual burden of tuberculosis and human immunodeficiency virus (HIV) is severely impacting the South African healthcare workforce. However, the use of on-site occupational health services is hampered by stigma among the healthcare workforce. The success of stigma-reduction interventions is difficult to evaluate because of a dearth of appropriate scientific tools to measure stigma in this specific professional setting.nnnMETHODSnThe current pilot study aimed to develop and test a range of scales measuring different aspects of stigma-internal and external stigma toward tuberculosis as well as HIV-in a South African healthcare setting. The study employed data of a sample of 200 staff members of a large hospital in Bloemfontein, South Africa.nnnRESULTSnConfirmatory factor analysis produced 7 scales, displaying internal construct validity: (1) colleagues external HIV stigma, (2) colleagues actions against external HIV stigma, (3) respondents external HIV stigma, (4) respondents internal HIV stigma, (5) colleagues external tuberculosis stigma, (6) respondents external tuberculosis stigma, and (7) respondents internal tuberculosis stigma. Subsequent analyses (reliability analysis, structural equation modeling) demonstrated that the scales displayed good psychometric properties in terms of reliability and external construct validity.nnnCONCLUSIONSnThe study outcomes support the use of the developed scales as a valid and reliable means to measure levels of tuberculosis- and HIV-related stigma among the healthcare workforce in a resource-limited context. Future studies should build on these findings to fine-tune the instruments and apply them to larger study populations across a range of different resource-limited healthcare settings with high HIV and tuberculosis prevalence.

On the Road to HIV/AIDS Competence in the Household: Building a Health-Enabling Environment for People Living with HIV/AIDS

When aiming to provide chronic disease care within the context of human resource shortages, we should not only consider the responsibility of the individual person living with HIV/AIDS (PLWHA) but also the capacity of the social environment to actively encourage a lifestyle that fosters health. In this social environment, extensive efforts are thus required to increase HIV/AIDS knowledge, reduce stigma, stimulate HIV testing, improve health care-seeking behavior, and encourage safe sexual practices—described in the literature as the need for AIDS competence. In accordance with socio-ecological theory, one cannot restrict the research focus to communities, as AIDS competence studies should also incorporate the intermediate household level. In responding to this research need, the aim of this article is to conceptualize an “HIV/AIDS competent household” based on qualitative interviews and focus group discussions conducted in a township on the outskirts of Cape Town, South Africa. Our results show that a household’s supportive response to disclosure allows a patient to live openly as HIV positive in the household concerned. This may mark the start of the road to HIV/AIDS competence in the household, meaning the PLWHA receives sustainable support throughout the care continuum and positive living becomes the norm for the PLWHA and his or her household. A feedback loop might also be created in which other household members are encouraged to be tested and to disclose their status, which is an important step towards a sustainable response to HIV/AIDS-related challenges. Despite the fact that this road to HIV/AIDS competence at the household level is fragile and prone to various barriers, this article shows that the household has the potential to be a health-enabling environment for PLWHA.

Measuring HIV- and TB-related stigma among health care workers in South Africa: a validation and reliability study

SETTINGnRecent evidence indicates that human immunodeficiency virus (HIV) and tuberculosis (TB) related stigma act as a key barrier to the utilisation of associated occupational health services by South African health care workers (HCWs). It also highlights a dearth of appropriate tools to measure HIV and TB stigma among HCWs.nnnOBJECTIVEnTo test four scales measuring different aspects of stigma: respondents external stigma (RES) and others external stigma (OES) towards TB as well as HIV across different professional categories of HCWs.nnnDESIGNnThe current study employs data from a study on HIV and TB stigma among HCWs, a cluster randomised controlled trial for the collection of data among 882 HCWs in the Free State Province of South Africa. Confirmatory factor analyses and structural equation modelling were used to assess the validity and reliability of the scales.nnnRESULTSnAll four scales displayed adequate internal construct validity. Subsequent analysis demonstrated that all four scales were metric-invariant, and that the OES scales were even scalar-invariant across patient and support staff groups. The scales displayed good reliability and external construct validity.nnnCONCLUSIONnOur results support the use of the scales developed to measure TB and HIV stigma among HCWs. Further research is, however, needed to fine tune the instruments and test them across different resource-limited countries.