Hailay Abrha Gesesew

Significant association between perceived HIV related stigma and late presentation for HIV/AIDS care in low and middle-income countries: A systematic review and meta-analysis

Background Late presentation for human immunodeficiency virus (HIV) care is a major impediment for the success of antiretroviral therapy (ART) outcomes. The role that stigma plays as a potential barrier to timely diagnosis and treatment of HIV among people living with HIV/AIDS (acquired immunodeficiency syndrome) is ambivalent. This review aimed to assess the best available evidence regarding the association between perceived HIV related stigma and time to present for HIV/AIDS care. Methods Quantitative studies conducted in English language between 2002 and 2016 that evaluated the association between HIV related stigma and late presentation for HIV care were sought across four major databases. This review considered studies that included the following outcome: ‘late HIV testing’, ‘late HIV diagnosis’ and ‘late presentation for HIV care after testing’. Data were extracted using a standardized Joanna Briggs Institute (JBI) data extraction tool. Meta- analysis was undertaken using Revman-5 software. I2 and chi-square test were used to assess heterogeneity. Summary statistics were expressed as pooled odds ratio with 95% confidence intervals and corresponding p-value. Results Ten studies from low- and middle- income countries met the search criteria, including six (6) and four (4) case control studies and cross-sectional studies respectively. The total sample size in the included studies was 3,788 participants. Half (5) of the studies reported a significant association between stigma and late presentation for HIV care. The meta-analytical association showed that people who perceived high HIV related stigma had two times more probability of late presentation for HIV care than who perceived low stigma (pooled odds ratio = 2.4; 95%CI: 1.6–3.6, I2 = 79%). Conclusions High perceptions of HIV related stigma influenced timely presentation for HIV care. In order to avoid late HIV care presentation due the fear of stigma among patients, health professionals should play a key role in informing and counselling patients on the benefits of early HIV testing or early entry to HIV care. Additionally, linking the systems and positive case tracing after HIV testing should be strengthened.

Farmers Knowledge, Attitudes, Practices and Health Problems Associated with Pesticide Use in Rural Irrigation Villages, Southwest Ethiopia.

Background In Ethiopia, pesticides are widely used for a variety of purposes. The occurrence of contamination and poisoning for farmers is highly reported due to unsafe handling practices and their usage. We assessed knowledge, attitudes and experiences of previous pesticide exposure, and related health problems among farmers who use irrigation in Jimma Zone, Southwest Ethiopia. Methods A community based cross-sectional study was conducted among farmers living in the zone. Respondents were 796 irrigation farmers from 20 kebeles (lowest administration unit) in Jimma Zone. Data were collected using a pretested and structured questionnaire via face-to-face interviews. Both descriptive and inferential statistics analysis were performed. A binary logistic regression was used to identify factors associated with attitudes of farmers towards the safe use of pesticides at P value of ≤ 0.05 in the final model. Results Among the participants, 54.4% (95%CI, 50.7–58%) knew at least one pesticide control method and 53.7% had positive attitudes towards safe use of pesticide. The mean score of attitudes was found to be 3.9(±0.4). Knowledge including each of the following: the names of the pesticides (AOR, 0.41; 95%CI, 0.25–0.67), methods of pest control and the use of gloves during pesticide exposure (AOR, 1.52; 95%CI, 1.07–2.16) was found to be independent predictor of the farmers’ attitudes about safe use of pesticides. Past exposure of pesticide was reported by 89.6% of farmers. Participants reported ingestion (88.9%) and inhalation (90.4%) as possible mechanisms of pesticide exposure. Nearly 42% of farmers had never used any personal protective equipment (PPE) to protect themselves against pesticide exposure. Farmers reported several health complications, which were perceived as complications of pesticide exposure, including: headache, nausea and vomiting, skin rash and irritation and abdominal pain. Conclusions The study exposed the existence of high probability of pesticide exposure, the low safe use of pesticide and the low use of PPE. However, but farmers had positive attitudes towards safe use of pesticides. These findings appeal for the development of effective public health strategies to improve farmers’ awareness and safe use of PPE. In addition, there is a need to inform farmers about integrated pest management to prevent severe health complications, which may occur as a result of unsafe and inappropriate use of pesticides.

Health Care Seeking Behavior in Southwest Ethiopia.

Background Rural and urban populations have disparate socio-demographic and economic characteristics, which have an influence on equity and their health seeking behavior. We examined and compared the health care seeking behavior for perceived morbidity between urban and rural households in Southwest Ethiopia. Methods Analytic cross-sectional study was conducted among urban and rural households living in Esera district of Southwest Ethiopia. A random sample of 388 head of households (126 urban and 262 rural) were selected. A pretested and structured questionnaire was used for data collection with face-to-face interview. In addition to descriptive methods, binary logistic regression was used to identify factors associated with health seeking behavior at p value of less than 0.05. Results Of the sample household heads, 377 (97.2%) (119 urban and 258 rural) were successfully interviewed. Among these, 58.4% (95% CI, 53.3–63.3%) of the households sought care from modern health care that was lower among rural (48.1%) than urban (80.7%) households. The prevalence of self-treatment was 35.3% in urban and 46.1% in rural households. Among the factors considered for modern health care utilization, higher monthly income (AOR, 5.6; 95% CI, 2.04–15.4), perceived severity of disease (AOR, 2.5; 95% CI, 1.1–5.8), acute duration of disease (AOR, 8.9; 95% CI, 2.4–33.3) and short distance from health facilities (AOR, 3; 95% CI, 1.2–8.4) among rural and being married (AOR, 11.3; 95% CI, 1.2–110.2) and perceived severity of disease (AOR, 6.6; 95% CI, 1.1–10.9) among urban households showed statistically significant association. Conclusions The general health seeking behavior of households on perceived morbidity was satisfactory but lower in rural compared to urban households. Self-medication was also widely practiced in the study area. The findings signal the need to work more on accessibility and promotion of healthcare seeking behavior especially among rural households.

Antimicrobial use in paediatric patients in a teaching hospital in Ethiopia

Background Antibiotics use in in children are different from adults due to a lack of data on pharmacokinetics, pharmacodynamics, efficacy and safety of drugs, different physiological spectrum, pediatrics populations being vulnerable to the majority of the illnesses, and the adverse effect of their irrational use is more serious. However, antibiotic use is not explored much in a paediatric population. The current study focused on antibiotic use among pediatric population using data from a tertiary hospital in Ethiopia. Methods A retrospective cross-sectional study collated data from 614 pediatrics patients admitted in pediatrics ward at Jimma University Teaching Hospital, Southwest Ethiopia. Descriptive analyses were performed to describe the type and pattern of antibiotics. The number of prescriptions per a patient was also compared with the WHO standard. Data analysis was carried out using SPSS version 20 for mackintosh. Results Antimicrobials were prescribed for 407(86.4%) patients of which 85.9% were in the form of injectables. A total of 1241 (90%) medicines were administered parenterally followed by oral 110 (8%). The maximum number of medicines per prescription was eight for all types of drugs in general, and five for antimicrobials in particular. All antimicrobials were prescribed empirically without any microbiological evidence. Pneumonia, sepsis and meningitis were the main reasons for antimicrobial use in the ward. Out of the total of 812 antibiotics prescribed; Penicillin G crystalline was the most (20%) frequently prescribed, followed by gentamicin (19%) and ampicillin (16). Conclusions Majority of the prescribed antibiotics were antimicrobials, and was in the form of injectables. Antimicrobials were over prescribed and the number of drugs per prescription was also far from WHO recommendation. Strict prescribing standard guidelines and treatment habits should be developed in the country, to prevent antimicrobial resistance.

The association between perceived HIV-related stigma and presentation for HIV/AIDS care in developing countries: a systematic review protocol

Review question/objective The objective of this review is to identify the best available evidence regarding the association between perceived HIV‐related stigma and presentation for HIV/AIDS care in developing countries. Background The 2012 UNAIDS global report indicates that approximately 34 million (31.4‐35.9 million) people were living with HIV at the end of 2011 globally.1 This report also stated that an estimated 0.8% of adults aged 15‐49 years worldwide are living with HIV; although the burden of the epidemic continues to vary considerably between countries and regions. In 2011, Sub‐Saharan Africa had one of the highest prevalence of HIV in the world; estimated at 4.9% of adults aged between 15 and 49. Following Sub‐Saharan Africa, the regions with the highest prevalence of HIV were the Caribbean, Eastern Europe and Central Asia, where 1.0% of adults were living with HIV in 2011. HIV infected patients in Europe and Africa are often diagnosed at advanced stages of disease due to multiple factors.2 There is no consensus on what should be considered delayed HIV care presentation and several definitions have been used to date. Some define when the diagnosis of an AIDS‐defining condition occurs either before or concomitantly to an HIV diagnosis,3 during the subsequent six months,4,5 or during the following year of an HIV diagnosis.6 Other definitions use CD4 cell count of <200 cells/&mgr;l,7 or <350 cells/&mgr;l.8 According to the 1993 expanded AIDS‐surveillance case definition, persons presenting with a CD4 cell count <200 cells/&mgr;l and/or with an AIDS‐defining disease are considered as delayed for HIV/AIDS care.9 Reducing the time that elapses between infection and the initiation of Anti‐Retroviral Therapy (ART) is important to decrease progression of the infection and to facilitate immunological recovery. Furthermore, delays in HIV/AIDS care can have serious public health implications. For example, opportunities to prevent further transmission through effective ART are lost and initiating treatment for HIV infection at an advanced stage leads to poorer outcomes than with early treatment.10 It also has economic implications for health services and society.11 Of the multiple factors that contribute to HIV‐infected patients presenting late for HIV/AIDS care (i.e. to be diagnosed, tested or treated), researchers suggest that perceived HIV‐related stigma plays a major contribution. Stigma can be explained as a process of devaluation that leads to shame and significantly discredits an individual in the eyes of others.12 HIV‐related stigma is multi‐layered, tending to build upon and reinforce negative implications via the association of HIV and AIDS with already‐marginalized behaviors, such as sex work, drug use and homosexual and transgender sexual practice.13 A study from Botswana suggested that HIV‐related stigma was a primary barrier to HIV testing in Botswana and other Sub‐Saharan African countries.14 The study showed that 40% of patients reported that they delayed getting tested for HIV and of these, 51% reported fear of a positive result as the main reason for delay in seeking treatment, which was often due to HIV‐related stigma. A case‐case comparison from Venezuela also reported that fear of HIV‐related stigma was a main barrier for HIV testing,15 and a case control study conducted in South Wollo, Ethiopia in 2010 found that people living with HIV/AIDS who perceived HIV stigma were three times more likely to present late to HIV/AIDS care than those who did not perceive HIV stigma.16 However, a case control study conducted in south west Ethiopia reported that HIV‐related stigma was not related with time to present for HIV care.17 Of course, the measurement of perceived HIV‐related stigma varies within the literature. For example, the studies conducted in Ethiopia used a 23‐item, four point Likert scale,18 whereas another used a nine‐item scale.19 Given there is ambiguity surrounding the association between perceived HIV related stigma and presentation for HIV care, the role of stigma as a potential barrier to the diagnosis and treatment of HIV among cohorts of individuals enrolling for HIV care in developing countries will be reviewed.

Prevalence, trend and risk factors for antiretroviral therapy discontinuation among HIV-infected adults in Ethiopia in 2003-2015

Background It is well acknowledged that antiretroviral therapy (ART) discontinuation hampers the progress towards achieving the UNAIDS treatment targets that aim to treat 90% of HIV diagnosed patients and achieve viral suppression for 90% of those on treatment. Nevertheless, the magnitude, trend and risk factors for ART discontinuation have not been explored extensively. We carried out a retrospective data analysis to assess prevalence, trend and risk factors for ART discontinuation among adults in Southwest Ethiopia. Methods 12 years retrospective cohort analysis was performed with 4900 HIV-infected adult patients between 21 June 2003 and 15 March 2015 registered at the ART clinic at Jimma University Teaching Hospital. ART discontinuation could be loss to follow-up, defaulting and/or stopping medication while remaining in care. Because data for 2003 and 2015 were incomplete, the 10 years data were used to describe trends for ART discontinuation using a line graph. We used binary logistic regression to identify factors that were correlated with ART discontinuation. To handle missing data, we applied multiple imputations assuming missing at random pattern. Results In total, 4900 adult patients enrolled on ART, of whom 1090 (22.3%) had discontinued, 954 (19.5%) had transferred out, 300 (6.1%) had died, 2517 (51.4%) were alive and on ART, and the remaining 39 (0.8%) had unknown outcome status. The trend of ART discontinuation showed an upward direction in the recent times and reached a peak, accounting for a magnitude of 10%, in 2004 and 2005. Being a female (AOR = 2.1, 95%CI: 1.7–2.8), having an immunological failure (AOR = 2.3, 1.9–8.2), having tuberculosis/HIV co-infection (AOR = 1.5, 1.1–2.1) and no previous history of HIV testing (AOR = 1.8, 1.4–2.9) were the risk factors for ART discontinuation. Conclusions One out of five adults had discontinued from ART, and the trend of ART discontinuation increased recently. Discontinued adults were more likely to be females, tuberculosis/HIV co-infected, with immunological failure and no history of HIV testing. Therefore, it is vital to implement effective programs such as community ART distribution and linkage-case-management to enhance ART linkage and retention.

Discontinuation from Antiretroviral Therapy: A Continuing Challenge among Adults in HIV Care in Ethiopia: A Systematic Review and Meta-Analysis.

Background Discontinuation of antiretroviral therapy (ART) reduces the immunological benefit of treatment and increases complications related to human immune-deficiency virus (HIV). However, the risk factors for ART discontinuation are poorly understood in developing countries particularly in Ethiopia. This review aimed to assess the best available evidence regarding risk factors for ART discontinuation in Ethiopia. Methods Quantitative studies conducted in Ethiopia between 2002 and 2015 that evaluated factors associated with ART discontinuation were sought across six major databases. Only English language articles were included. This review considered studies that included the following outcome: ART treatment discontinuation, i.e. ‘lost to follow up’, ‘defaulting’ and ‘stopping medication’. Meta- analysis was performed with Mantel Haenszel method using Revman-5 software. Summary statistics were expressed as pooled odds ratio with 95% confidence intervals at a p-value of <0.05. Results Nine (9) studies met the criteria of the search. Five (5) were retrospective studies, 3 were case control studies, and 1 was a prospective cohort study. The total sample size in the included studies was 62,156. Being rural dweller (OR = 2.1, 95%CI: 1.5–2.7, I2 = 60%), being illiterate (OR = 1.5, 95%CI: 1.1–2.1), being not married (OR = 1.4, 95%CI: 1.1–1.8), being alcohol drinker (OR = 2.9, 95%CI: 1.9–4.4, I2 = 39%), being tobacco smoker (OR = 2.6, 95%CI: 1.6–4.3, I2 = 74%), having mental illness (OR = 2.7, 95%CI: 1.6–4.6, I2 = 0%) and being bed ridden functional status (OR = 2.3, 95%CI: 1.5–3.4, I2 = 37%) were risk factors for ART discontinuation. Whereas, having HIV positive partner (OR = 0.4, 95%CI: 0.3–0.6, I2 = 69%) and being co-infected with Tb/HIV (OR = 0.6, 95%CI: 0.4–0.9, I2 = 0%) were protective factors. Conclusion Demographic, behavioral and clinical factors influenced ART treatment discontinuation. Hence, we recommend strengthening decentralization of HIV care services in remote areas, strengthening of ART task shifting, application of seek-test-treat-succeed model, and integration of smoking cession strategies and mental health care into the routine HIV care program.

Factors associated with discontinuation of anti-retroviral therapy among adults living with HIV/AIDS in Ethiopia: a systematic review protocol

REVIEW QUESTION/OBJECTIVE The aim of this review is to assess the best available evidence regarding risk factors for discontinuation from anti-retroviral therapy in Ethiopia. Specifically, the review will be assessing the association between discontinuation from anti-retroviral therapy and the following: Socio-demographic and economic factors Behavioral factors Clinical factors Institutional factors INCLUSION CRITERIA Types of participants This review will consider studies reporting on HIV-positive participants aged 15 years and older who have commenced anti-retroviral therapy. Patients who have been transferred out will be excluded. Patients should have at least one follow-up time. If studies include both adult and pediatrics, and are not stratified by age (pediatrics and adults) during analysis, they will be excluded. Besides, if the studies focus on attrition (mortality or discontinuation) and are not stratified by mortality and discontinuation during analysis, the study will also be excluded. Types of exposure This review will consider studies that have examined risk factors for anti-retroviral therapy treatment discontinuation. These include socio-demographic and economic risk factors such as age, sex, income and being dependent on food supplies; behavioral risk factors such as mental status, presence of bereavement, the partner’s HIV status and fear stigma; clinical factors such as isoniazid prophylaxis provision, presence of side effects, baseline CD4 counts and regimen substitution; and institutional risk factors such as distance from the facility and waiting times. Types of outcomes This review will consider studies that include the following outcomes: anti-retroviral therapy treatment discontinuation, i.e. lost to follow up, drop out or defaulting and stopping TRUNCATED AT 250 WORDS

Early mortality among children and adults in antiretroviral therapy programs in Southwest Ethiopia, 2003-15

Background Several studies reported that the majority of deaths in HIV-infected people are documented in their early antiretroviral therapy (ART) follow-ups. Early mortality refers to death of people on ART for follow up period of below 24 months due to any cause. The current study assessed predictors of early HIV mortality in Southwest Ethiopia. Methods We have conducted a retrospective analysis of 5299 patient records dating from June 2003- March 2015. To estimate survival time and compare the time to event among the different groups of patients, we used a Kaplan Meir curve and log-rank test. To identify mortality predictors, we used a cox regression analysis. We used SPSS-20 for all analyses. Results A total of 326 patients died in the 12 years follow-up period contributing to 6.2% cumulative incidence and 21.7 deaths per 1000 person-year observations incidence rate. Eighty-nine percent of the total deaths were documented in the first two years follow up—an early-term ART follow up. Early HIV mortality rates among adults were 50% less in separated, divorced or widowed patients compared with never married patients, 1.6 times higher in patients with baseline CD4 count <200 cells/μL compared to baseline CD4 count ≥200 cells/μL, 1.5 times higher in patients with baseline WHO clinical stage 3 or 4 compared to baseline WHO clinical stage 1 or 2, 2.1 times higher in patients with immunologic failure compared with no immunologic failure, 60% less in patients with fair or poor compared with good adherence, 2.9 times higher in patients with bedridden functional status compared to working functional status, and 2.7 times higher with patients who had no history of HIV testing before diagnosis compared to those who had history of HIV testing. Most predictors of early mortality remained the same to the predictors of an overall HIV mortality. When discontinuation was assumed as an event, the predictors of an overall HIV mortality included age between 25–50 years, base line CD4 count, developing immunologic failure, bedridden functional status, and no history of HIV testing before diagnosis. Conclusions The great majority of deaths were documented in the first two years of ART, and several predictors of early HIV mortality were also for the overall mortality when discontinuation was assumed as event or censored. Considering the above population, interventions to improve HIV program in the first two years of ART follow up should be improved.

Immunological failure in HIV-infected adults from 2003 to 2015 in Southwest Ethiopia: a retrospective cohort study

Objective To assess the prevalence, trend and associated factors for immunological failure (IF), and the magnitude of antiretroviral therapy (ART) shift among adults infected with HIV in Southwest Ethiopia. Setting A retrospective cohort study was undertaken using the data from ART clinic at Jimma University Teaching Hospital from 21 June 2003 to 15 March 2015. Participants Retrospective analysis of 4900 HIV-infected adult patient records dating from June 2003 to March 2015 was conducted. Primary outcome measure The primary outcome was IF defined when cluster for differentiation 4 (CD4) count falls to the baseline (or below) or persistent CD4 levels below 100 cells/mm3 after 6 months of ART treatment. The analyses included descriptive and inferential statistics. Results 546 (19.5%) adults had developed clinical failure (CF), 775 (19.7%) adults had developed IF and 1231 (25.1%) had developed either CF or IF or both. The prevalence of IF was consistently high throughout the decade. Age 25 to ≤50 years adjusted OR (AOR 1.5, 9% CI 1.2 to 2.4), being female (AOR 1.8, 95% CI 1.3 to 1.9), late presenter for HIV care (AOR 2.2, 95% CI 1.6 to 2.7) and having baseline CD4 count below 200 cells/mm3 (AOR 5.5, 95% CI 4.1 to 7.4), and having no history of HIV testing before diagnosis (AOR 0.7, 95% CI 0.5 to 0.9) were the predictors for IF. Only 29 (0.9%) adults infected with HIV were shifted to second-line ART regimen. Conclusions The magnitude of CF or IF or both was found significant and consistently high throughout the calendar year although ART shift was found minimal. HIV-infected adult patients with IF were early age adults, females, late presenters for HIV care, and those who had low baseline CD4 counts and history of HIV testing before diagnosis.