Laura K. Beres

Making sense of abstinence: social representations in young Africans' HIV-related narratives from six countries

Despite the prominence of abstinence promotion in HIV prevention for young Africans, there is little documentation concerning its reception and interpretation. With the purpose of informing programmatic practice, we examined how young Africans from six countries with contrasting HIV prevalence rates make sense of abstinence. ‘Scenarios from Africa’ scriptwriting contests invite young people to contribute ideas for short films about HIV. Using thematic narrative-based approaches, we analyzed a stratified random sample of these narratives written in 2005 by young women and men aged 10–24 years from Senegal, Burkina Faso, South-East Nigeria, Kenya, Namibia and Swaziland. Abstinence was considerably more prominent as a theme in the samples from SE Nigeria, Kenya and Swaziland. It was articulated in relation to conservative Christian sexual morality and in opposition to condom use with particular intensity in SE Nigeria, with stigmatising implications for non-abstainers. However, cross-national commonalities were more striking than differences. Examples of non-stigmatising pro-abstinence messaging highlighted the appeal of discourses of romantic love and future plans across countries and demographic characteristics. The analysis yielded contextual understanding, youth-driven ideas and recommendations to inform comprehensive HIV-prevention efforts.

A Preliminary Assessment of Rotavirus Vaccine Effectiveness in Zambia

BACKGROUND Diarrhea is the third leading cause of child death in Zambia. Up to one-third of diarrhea cases resulting in hospitalization and/or death are caused by vaccine-preventable rotavirus. In January 2012, Zambia initiated a pilot introduction of the Rotarix live, oral rotavirus vaccine in all public health facilities in Lusaka Province. METHODS Between July 2012 and October 2013, we conducted a case-control study at 6 public sector sites to estimate rotavirus vaccine effectiveness (VE) in age-eligible children presenting with diarrhea. We computed the odds of having received at least 1 dose of Rotarix among children whose stool was positive for rotavirus antigen (cases) and children whose stool was negative (controls). We adjusted the resulting odds ratio (OR) for patient age, calendar month of presentation, and clinical site, and expressed VE as (1 - adjusted OR) × 100. RESULTS A total of 91 rotavirus-positive cases and 298 rotavirus-negative controls who had under-5 card-confirmed vaccination status and were ≥6 months of age were included in the case-control analysis. Among rotavirus-positive children who were age-eligible to be vaccinated, 20% were hospitalized. Against rotavirus diarrhea of all severity, the adjusted 2-dose VE was 26% (95% confidence interval [CI], -30% to 58%) among children ≥6 months of age. VE against hospitalized children ≥6 months of age was 56% (95% CI, -34% to 86%). CONCLUSIONS We observed a higher point estimate for VE against increased severity of illness compared with milder disease, but were not powered to detect a low level of VE against milder disease.

Integration of Family Planning Services into HIV Care and Treatment Services: A Systematic Review

Evidence on the feasibility, effectiveness, and cost‐effectiveness of integrating family planning (FP) and HIV services has grown significantly since the 2004 Glion Call to Action. This systematic review adds to the knowledge base by characterizing the range of models used to integrate FP into HIV care and treatment, and synthesizing the evidence on integration outcomes among women living with HIV. Fourteen studies met our inclusion criteria, eight of which were published after the last systematic review on the topic in 2013. Overall, integration was associated with higher modern method contraceptive prevalence and knowledge, although there was insufficient evidence to evaluate its effects on unintended pregnancy or achieving safe and healthy pregnancy. Evidence for change in unmet need for FP was limited, although two of the three evaluations that measured unmet need suggested possible improvements associated with integrated services. However, improving access to FP services through integration was not always sufficient to increase the use of more effective (noncondom) modern methods among women who wanted to prevent pregnancy. Integration efforts, particularly in contexts where contraceptive use is low, must address community‐wide and HIV‐specific barriers to using effective FP methods alongside improving access to information, commodities, and services within routine HIV care.

Making sense of HIV testing: Social representations in young Africans' HIV-related narratives from six countries

HIV testing and counselling are a critical intervention to support treatment access and prevent new infections. Despite high rates of infection, few young Africans know their HIV status. With the aim of informing initiatives that encourage HIV testing and access to testing benefits, this study seeks to understand how young Africans make sense of HIV testing. We conducted thematic narrative-based analysis of a stratified random sample (n = 586, ∼5%) from 11,354 narratives written in 2005 by males and females aged 10–24 from six sub-Saharan African countries for the ‘Scenarios from Africa’ scriptwriting contest which invites young people to contribute ideas for short films about HIV. The factors represented by the young authors as influencing testing behaviour and outcomes are complex and interactive, indicating that interventions that are not contextually appropriate are unlikely to affect a shift towards increased testing or improved post-testing outcomes. The narratives point to opportunities to increase HIV testing in this demographic.

Estimated mortality on HIV treatment among active patients and patients lost to follow-up in 4 provinces of Zambia: Findings from a multistage sampling-based survey.

Background Survival represents the single most important indicator of successful HIV treatment. Routine monitoring fails to capture most deaths. As a result, both regional assessments of the impact of HIV services and identification of hotspots for improvement efforts are limited. We sought to assess true mortality on treatment, characterize the extent under-reporting of mortality in routine health information systems in Zambia, and identify drivers of mortality across sites and over time using a multistage, regionally representative sampling approach. Methods and findings We enumerated all HIV infected adults on antiretroviral therapy (ART) who visited any one of 64 facilities across 4 provinces in Zambia during the 24-month period from 1 August 2013 to 31 July 2015. We identified a probability sample of patients who were lost to follow-up through selecting facilities probability proportional to size and then a simple random sample of lost patients. Outcomes among patients lost to follow-up were incorporated into survival analysis and multivariate regression through probability weights. Of 165,464 individuals (64% female, median age 39 years (IQR 33–46), median CD4 201 cells/mm3 (IQR 111–312), the 2-year cumulative incidence of mortality increased from 1.9% (95% CI 1.7%–2.0%) to a corrected rate of 7.0% (95% CI 5.7%–8.4%) (all ART users) and from 2.1% (95% CI 1.8%–2.4%) to 8.3% (95% CI 6.1%–10.7%) (new ART users). Revised provincial mortality rates ranged from 3–9 times higher than naïve rates for new ART users and were lowest in Lusaka Province (4.6 per 100 person-years) and highest in Western Province (8.7 per 100 person-years) after correction. Corrected mortality rates varied markedly by clinic, with an IQR of 3.5 to 7.5 deaths per 100 person-years and a high of 13.4 deaths per 100 person-years among new ART users, even after adjustment for clinical (e.g., pretherapy CD4) and contextual (e.g., province and clinic size) factors. Mortality rates (all ART users) were highest year 1 after treatment at 4.6/100 person-years (95% CI 3.9–5.5), 2.9/100 person-years (95% CI 2.1–3.9) in year 2, and approximately 1.6% per year through 8 years on treatment. In multivariate analysis, patient-level factors including male sex and pretherapy CD4 levels and WHO stage were associated with higher mortality among new ART users, while male sex and HIV disclosure were associated with mortality among all ART users. In both cases, being late (>14 days late for appointment) or lost (>90 days late for an appointment) was associated with deaths. We were unable to ascertain the vital status of about one-quarter of those lost and selected for tracing and did not adjudicate causes of death. Conclusions HIV treatment in Zambia is not optimally effective. The high and sustained mortality rates and marked under-reporting of mortality at the provincial-level and unexplained heterogeneity between regions and sites suggest opportunities for the use of corrected mortality rates for quality improvement. A regionally representative sampling-based approach can bring gaps and opportunities for programs into clear epidemiological focus for local and global decision makers.

Missed opportunities: HIV and the 2010 FIFA World Cup

The international community missed opportunities to raise HIV awareness and reduce transmission risk during the World Cup held in South Africa from 11 June-11 July 2010. With the tournament captivating the entire region, the public health community should have better applied our knowledge and evidence-based interventions to raise the profile of HIV prevention, care and treatment. More should have been done to prevent possible new infections fueled by visitors, alcohol and sports celebrations. Considering the impact of HIV in southern Africa and the amount of funds and effort that go into addressing the problem each year, we cannot afford to miss these opportunities for action.

Rethinking retention: Mapping interactions between multiple factors that influence long-term engagement in HIV care

Background Failure to keep people living with HIV engaged in life-long care and treatment has serious implications for individual and population-level health. Nested within a four-province study of HIV care and treatment outcomes, we explored the dynamic role of social and service-related factors influencing retention in HIV care in Zambia. Methods From a stratified random sample of 31 facilities, eight clinics were selected, one urban and one rural from each province. Across these sites we conducted a total of 69 in-depth interviews, including with patients (including pregnant women) engaged in-care (n = 28), disengaged from care (n = 15), engaged facility transferee (n = 12), and friends/family of deceased patients (n = 14). At the same sites we conducted 24 focus group discussions with a total of 192 lay and professional healthcare workers (HCWs). Two-day observations in each of the eight facilities helped triangulate data on operational context, provider relations and patient-provider interactions. We ordered and analysed data using an adapted version of Ewart’s Social Action Theory. Results Three overarching findings emerged. First, the experience of living with HIV and engaging in HIV care in Zambia is a social, not individual experience, influenced by social and gendered norms and life goals including financial stability, raising family and living stigma-free. Second, patients and their networks act collectively to negotiate and navigate HIV care. Anticipated responses from social network influenced patients’ willingness to engage in care, while emotional and material support from those networks influenced individuals’ capacity to remain in HIV care. Lastly, health system factors were most influential where they facilitated or undermined peoples’ collective approach to health service use. Participants living with HIV reported facilitation of both their initial and continued engagement in care where services involved social networks, such as during couples testing and community outreach. Conversely, service features that were poorly aligned with respondents’ social reality (e.g. workplace obligations) hindered long-term engagement. Conclusions This study moves beyond listing barriers or socio-ecological groupings, to explain how social and health systems interact to produce HIV care outcomes. Our findings challenge the implicit assumption of individual agency underpinning many retention studies to highlight the social nature of illness and healthcare utilization for HIV in Zambia. This understanding of collective action for accessing and remaining in HIV care should underpin future efforts to revise and reform HIV and potentially other chronic service models and systems.

Understanding preferences for HIV care and treatment in Zambia: Evidence from a discrete choice experiment among patients who have been lost to follow-up

Background In public health HIV treatment programs in Africa, long-term retention remains a challenge. A number of improvement strategies exist (e.g., bring services closer to home, reduce visit frequency, expand hours of clinic operation, improve provider attitude), but implementers lack data about which to prioritize when resource constraints preclude implementing all. We used a discrete choice experiment (DCE) to quantify preferences for a number of potential clinic improvements to enhance retention. Methods and findings We sought a random sample of HIV patients who were lost to follow-up (defined as >90 days late for their last scheduled appointment) from treatment facilities in Lusaka Province, Zambia. Among those contacted, we asked patients to choose between 2 hypothetical clinics in which the following 5 attributes of those facilities were varied: waiting time at the clinic (1, 3, or 5 hours), distance from residence to clinic (5, 10, or 20 km), ART supply given at each refill (1, 3, or 5 months), hours of operation (morning only, morning and afternoon, or morning and Saturday), and staff attitude (“rude” or “nice”). We used mixed-effects logistic regression to estimate relative utility (i.e., preference) for each attribute level. We calculated how much additional waiting time or travel distance patients were willing to accept in order to obtain other desired features of care. Between December 9, 2015 and May 31, 2016, we offered the survey to 385 patients, and 280 participated (average age 35; 60% female). Patients exhibited a strong preference for nice as opposed to rude providers (relative utility of 2.66; 95% CI 1.9–3.42; p < 0.001). In a standard willingness to wait or willingness to travel analysis, patients were willing to wait 19 hours more or travel 45 km farther to see nice rather than rude providers. An alternative analysis, in which trade-offs were constrained to values actually posed to patients in the experiment, suggested that patients were willing to accept a facility located 10 km from home (as opposed to 5) that required 5 hours of waiting per visit (as opposed to 1 hour) and that dispensed 3 months of medications (instead of 5) in order to access nice (as opposed to rude) providers. This study was limited by the fact that attributes included in the experiment may not have captured additional important determinants of preference. Conclusions In this study, patients were willing to expend considerable time and effort as well as accept substantial inconvenience in order to access providers with a nice attitude. In addition to service delivery redesign (e.g., differentiated service delivery models), current improvement strategies should also prioritize improving provider attitude and promoting patient centeredness—an area of limited policy attention to date.

Non-specialist psychosocial support interventions for women living with HIV: A systematic review

ABSTRACT Many women living with HIV experience a range of physical, social, and psychological challenges linked to their HIV status. Psychosocial support interventions may help women cope with these challenges and may allow women to make better decisions around their sexual and reproductive health (SRH), yet no reviews have summarized the evidence for the impact of such interventions on well-being and SRH decision-making among women living with HIV. We systematically reviewed the evidence for non-specialist delivered psychosocial support interventions for women living with HIV, which are particularly relevant in low-resource settings. Outcomes of interest included mental, emotional, social well-being and/or quality of life, common mental health disorders, and SRH decision-making. Searching was conducted through four electronic databases and secondary reference screening. Systematic methods were used for screening and data abstraction. Nine articles met the inclusion criteria, showing positive or mixed results for well-being and depressive symptoms indicators. No studies reported on SRH decision-making outcomes. The available evidence suggests that psychosocial support interventions may improve self-esteem, coping and social support, and reduce depression, stress, and perceived stigma. However, evidence is mixed. Most studies placed greater emphasis on instrumental health outcomes to prevent HIV transmission than on the intrinsic well-being and SRH of women living with HIV. Many interventions included women living with HIV in their design and implementation. More research is required to understand the most effective interventions, and their effect on sexual and reproductive health and rights.

Antituberculosis Drug Resistance Survey in Lesotho, 2008-2009: Lessons Learned.

Setting Drug resistance is an increasing threat to tuberculosis (TB) control worldwide. The World Health Organization advises monitoring for drug resistance, with either ongoing surveillance or periodic surveys. Methods The antituberculosis drug resistance survey was conducted in Lesotho in 2008-2009. Basic demographic and TB history information was collected from individuals with positive sputum smear results at 17 diagnostic facilities. Additional sputum sample was sent to the national TB reference laboratory for culture and drug susceptibility testing. Results Among 3441 eligible smear-positive persons, 1121 (32.6%) were not requested to submit sputum for culture. Among 2320 persons submitted sputum, 1164 (50.2%) were not asked for clinical information or did not have valid sputum samples for testing. In addition, 445/2320 (19.2%) were excluded from analysis because of other laboratory or data management reasons. Among 984/3441 (28.6%) persons who had data available for analysis, MDR-TB was present in 24/773 (3.1%) of new and 25/195 (12.8%) of retreatment TB cases. Logistical, operational and data management challenges affected survey results. Conclusion MDR-TB is prevalent in Lesotho, but limitations reduced the reliability of our findings. Multiple lessons learned during this survey can be applied to improve the next drug resistance survey in Lesotho and other resource constrained countries may learn how to avoid these bottlenecks.