Edwin Wouters

Public-sector ART in the Free State Province, South Africa: Community support as an important determinant of outcome

The treatment outcomes for large-scale public antiretroviral therapy (ART) programs in developing countries, although promising, are still preliminary. The scaling-up of ART in resource-limited settings is inevitably hampered by human resource shortages. Therefore, community support for ART patients may play an important role in achieving favorable treatment outcomes. This study aimed to extend the current literature by investigating how immunological and virological responses to ART, measured at three points in time (after six, 12, and 24 months of ART), are influenced by patient characteristics (age, sex), health literacy (educational level and knowledge about HIV/AIDS), baseline CD4 cell count, baseline viral load, and three forms of community support (treatment buddy, community health worker [CHW], and HIV/AIDS support group). Cross-lagged regression analysis was used to test these relationships in a sample of 268 patients enrolled in the public-sector ART program of the Free State Province of South Africa (2004-2007). After 24 months of ART, 76.4% of patients were classified as treatment successes (viral load < 400 copies/mL, CD4 > or = 200 cells/microL), compared with 64.1% at 12 months and 46.1% at six months. When we examined the predictors of ART success, baseline health and all three community support initiatives had a positive effect on ART outcomes after six months, whereas patient characteristics had little effect. Six months later, patients with the support of a treatment buddy, CHW, or support group had better ART outcomes, whereas the impact of baseline health had diminished. After two years of treatment, community support again emerged as the most important predictor of treatment success. This study confirms that the ART provided by South African public-sector health services is effective. These results provide evidence from the field that communities can be mobilized to sustain these favorable outcomes under conditions of limited human resources for healthcare.

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.

Anxiety and depression amongst patients enrolled in a public sector antiretroviral treatment programme in South Africa: a cross- sectional study

BackgroundHIV/AIDS and depression are projected to be the two leading causes of disability by 2030. HIV/AIDS and anxiety/depression are interlinked. People suffering from depression may be more likely to engage in risky sexual behaviour, and therefore at greater risk of contracting HIV. An HIV + diagnosis may trigger symptoms of anxiety and depression, which may in turn result in risky sexual behaviour and the spread of HIV. This study explores correlates of anxiety and depression in patients enrolled in a public sector ART programme in South Africa.MethodsInterviews were conducted with 716 patients initiating ART at twelve public health care facilities in the Free State. Symptoms of anxiety and depression were measured using the Hospital Anxiety and Depression Scale (HADS). An 8+ cut-off was used to identify possible cases of anxiety and depression. Multivariate logistic regression analysis, using STATA Version 11, was performed to identify correlates of anxiety and depression.ResultsThe prevalence of symptoms of respectively anxiety and depression amongst this study population in the Free State was 30.6% and 25.4%. The multivariate logistic regression analyses identified five correlates of symptoms of anxiety and depression. Disruptive side effects (OR = 3.62, CI 1.95-6.74) and avoidant coping (OR = 1.42, CI 1.22-1.65) were associated with a greater number of symptoms of anxiety. Stigma was associated with an increase in symptoms of anxiety (OR = 1.14, CI 1.07-1.21) and of depression (OR = 1.13, CI 1.06-1.20), while being a widow (OR = 0.30, CI 0.13-0.69) and participating in a support group (OR = 0.21, CI 0.05-0.99) were associated with decreased symptoms of depression.ConclusionsThe findings from the study provide valuable insights into the psychosocial aspects of the Free State public-sector ART programme. Combined with the literature on the intricate link between mental health problems and treatment outcomes our results emphasise firstly, the necessity that resources be allocated for both screening and treating mental health problems and, secondly, the need for interventions that will encourage support-group participation, address ART side effects, reduce maladaptive coping styles, and minimise the stigma associated with symptoms of anxiety and/or depression.

Community support and disclosure of HIV serostatus to family members by public-sector antiretroviral treatment patients in the Free State Province of South Africa.

Recent studies have indicated that the support of close relatives is fundamental in coping with HIV/AIDS and in accessing the emotional and material support necessary for sustained adherence to treatment. Because disclosure to family members is imperative to ensure their support, identifying tools or resources that can minimize the possible risks and maximize the potential benefits of disclosure should be useful in improving the lives of people living with HIV/AIDS. Where health systems require strengthening, engaging the community in HIV/AIDS care could potentially create an environment that encourages disclosure to family members. This study investigated the impact of community support initiatives (community health workers and treatment support groups), patient characteristics (age, gender, and education), and time since first diagnosis on the disclosure of serostatus to family members by a sample of 268 public-sector antiretroviral treatment patients in a province of South Africa between August 2004 and July 2007. Whereas gender, age, and education only weakly influenced disclosure, there was a strong and stable positive association between community support and disclosure to family members. The immediate and long-term impact of community support on the disclosure by seropositive patients to family members indicates that initiatives such as community health workers and HIV support groups run by people living with HIV/AIDS should be strengthened, especially for those patients who cannot disclose their status to immediate family and close friends.

Food Insecurity Is Associated with Increased Risk of Non-Adherence to Antiretroviral Therapy among HIV-Infected Adults in the Democratic Republic of Congo: A Cross-Sectional Study.

Background Food insecurity is increasingly reported as an important barrier of patient adherence to antiretroviral therapy (ART) in both resource-poor and rich settings. However, unlike in resource rich-settings, very few quantitative studies to date have investigated the association of food insecurity with patient adherence to ART in Sub-Saharan Africa. The current study examines the association between food insecurity and adherence to ART among HIV-infected adults in the Democratic Republic of Congo (DRC). Methods and Findings This is a cross-sectional quantitative study of patients receiving ART at three private and one public health facilities in Kinshasa, DRC. Participants were consecutively recruited into the study between April and November 2012. Adherence was measured using a combined method coupling pharmacy refill and self-reported adherence. Food insecurity was the primary predictor, and was assessed using the Household Food Insecurity Access Scale (HFIAS). Of the 898 participants recruited into the study, 512 (57%) were food insecure, and 188 (20.9%) were not adherent to ART. Food insecurity was significantly associated with non-adherence to ART (AOR, 2.06; CI, 1.38–3.09). We also found that perceived harmfulness of ART and psychological distress were associated respectively with increased (AOR, 1.95; CI, 1.15–3.32) and decreased (AOR, 0.31; CI, 0.11–0.83) odds of non-adherence to ART. Conclusion Food insecurity is prevalent and a significant risk factor for non-adherence to ART among HIV-infected individuals in the DRC. Our findings highlight the urgent need for strategies to improve food access among HIV-infected on ART in order to ensure patient adherence to ART and ultimately the long-term success of HIV treatment in Sub-Saharan Africa.

Slow to share: social capital and its role in public HIV disclosure among public sector ART patients in the Free State province of South Africa.

Abstract HIV serostatus disclosure to community members has been shown to have potential public and personal health benefits. This study examined the impact of bonding and bridging social capital (i.e. close and distant ties) on public disclosure and described the complex relationship between bonding and bridging social capital in the context of serostatus disclosure among AIDS patients enrolled in South Africas public sector antiretroviral treatment (ART) program. Data were collected from a cohort of patients enrolled in the public sector ART program in the Free State province of South Africa. Semi-structured, face-to-face interviews were conducted with a random sample of 268 patients at three points in time (<6 months of ART, 6–12 months of ART, and 18–24 of months ART). The relationship between bonding and bridging social capital and the impact of different forms of social capital on public disclosure were determined using a fully cross-lagged regression model. The impact of bonding social capital (treatment and emotional buddy) on public disclosure was positive and invariant across time. The results from the cross-lagged regression indicated that bridging social capital (community health worker and support group) only encouraged public disclosure in the second year of treatment. At the start of treatment, bivariate analysis showed a strong negative association between bonding and bridging social capital, which diminished at follow-up and eventually disappeared in the second year of treatment. This study identified bonding social capital as a leverage to maximize potential benefits and minimize potential risks in order to shift the balance toward consistent public disclosure. Furthermore, the importance of bridging social capital initiatives is demonstrated, especially for the most vulnerable patients, those who cannot capitalize their bonding social capital by disclosing their HIV serostatus to family and friends at the start of treatment.

Positive spill-over effects of ART scale up on wider health systems development: evidence from Ethiopia and Malawi

BackgroundGlobal health initiatives have enabled the scale up of antiretroviral treatment (ART) over recent years. The impact of HIV-specific funds and programmes on non-HIV-related health services and health systems in genera has been debated extensively. Drawing on evidence from Malawi and Ethiopia, this article analyses the effects of ART scale-up interventions on human resources policies, service delivery and general health outcomes, and explores how synergies can be maximized.MethodsData from Malawi and Ethiopia were compiled between 2004 and 2009 and between 2005 and 2009, respectively. We developed a conceptual health systems framework for the analysis. We used the major changes in human resources policies as an entry point to explore the wider health systems changes.ResultsIn both countries, the need for an HIV response triggered an overhaul of human resources policies. As a result, the health workforce at health facility and community level was reinforced. The impact of this human resources trend was felt beyond the scale up of ART services; it also contributed to an overall increase in functional health facilities providing curative, mother and child health, and ART services. In addition to a significant increase in ART coverage, we observed a remarkable rise in user rates of non-HIV health services and an improvement in overall health outcomes.ConclusionsInterventions aimed at the expansion of ART services and improvement of long-term retention of patients in ART care can have positive spill-over effects on the health system. The responses of Malawi and Ethiopia to their human resources crises was exceptional in many respects, and some of the lessons learnt can be useful in other contexts. The case studies show the feasibility of obtaining improved health outcomes beyond HIV through scaled-up ART interventions when these are part of a long-term, system-wide health plan supported by all decision makers and funders.

Impact of baseline health and community support on antiretroviral treatment outcomes in HIV patients in South Africa.

The importance of community support when scaling-up antiretroviral treatment (ART) in resource-limited settings is poorly understood. We assessed the impact of baseline health, patient characteristics and community support on ART outcomes at 6 and 12 months in a representative sample of 268 patients enrolled in the Free State public sector ART program (South Africa). Delayed ART initiation reduced ART response, whereas support from treatment buddies, community health workers and support groups significantly improved treatment outcomes.

If I have nothing to eat, I get angry and push the pills bottle away from me: A qualitative study of patient determinants of adherence to antiretroviral therapy in the Democratic Republic of Congo.

The global response to the HIV/AIDS epidemic has improved access to antiretroviral therapy (ART) and has contributed to decreased HIV/AIDS morbidity and mortality in sub-Saharan Africa. Patient adherence to ART is crucial to the success of HIV/AIDS treatment. However, little is known about the determinants of adherence to ART among people living with HIV/AIDS (PLWHA) in the Democratic Republic of Congo (DRC). This qualitative study used in-depth semi-structured patient interviews, a purposive sampling strategy and thematic analysis scheme to identify barriers and facilitators of adherence to ART in the DRC. We recruited three categories of participants from the Centre Hospitalier Monkole and the NGO ACS/Amo-Congo including participants on antiretroviral (ARV) treatment (n=19), on ARV re-treatment (n=13) and lost to follow-up (n=6). Among 38 participants interviewed, 24 were female and the median age was 41 years. Food insecurity as a barrier to adherence emerged as a dominant theme across the three categories of participants. Other barriers included financial constraints, forgetfulness and fear of disclosure/stigma. Religious beliefs were both a barrier and a facilitator to ART adherence. We found that food insecurity was a common and an important barrier to ART adherence among patients in the DRC. Our findings suggest that food insecurity should be appropriately addressed and incorporated into ARV treatment programs to ensure patient adherence and ultimately the long-term success of HIV treatment in the region.

The Influence of Mothers' and Fathers' Parenting Stress and Depressive Symptoms on Own and Partner's Parent-Child Communication

This study examines how parenting stress and depressive symptoms experienced by mothers and fathers influence their own (actor effects) and the partners (partner effects) parent-child communication. Based on the Actor-Partner Interdependence Model, data from 196 families were analyzed, with both parents rating their parenting stress and depressive feelings, and parents as well as children rating the open parent-child communication. Actor effects were found between parenting stress and open parent-child communication, whereas partner effects were prominent between depressive symptoms and open parent-child communication. The results provide no evidence for gender differences in the strength of the pathways to open parent-child communication. Our findings demonstrate the need to include both parents in studies on parent-child communication to enhance our understanding of the mutual influence among family members.